[Ethics in preclinical emergency medicine--on the topic of medical futility and resuscitation efforts].

Abstract

In prehospital emergency medicine, physicians are repeatedly faced with the question of when cardiopulmonary resuscitation (CPR) efforts should be withheld or terminated since they are clearly futile. Here, futile means the goal of saving life cannot be achieved. Determining futility involves qualitative und quantitative aspects. Does the possibility of simply restoring circulatory function justify the decision to initiate resuscitation or must the prospect of a prolonged meaningful life exist? The question of futility arises for the entire life-saving team during resuscitation efforts, for example, after traumatic cardiopulmonary arrest, prolonged down time, collapses in chronically-sick nursing home residents or during transport to hospital when prehospital CPR failed to restore spontaneous circulation. Possible solutions to this problem lie in restricting the objective of resuscitation to achieving a physiological effect in an organ system, i.e. regaining the cardiac pumping function, and in taking into account the chance of long-term survival and quality of life of the patient. Basically speaking, general ethical principles must be adhered to and these include consideration of a patient's right to self-determination. In the prehospital setting, however, the emergency physician is usually confronted with an unknown and unconscious patient and has no information about his preferences. In general, the patient's will to live and his desire for every effort to be made to save him can be assumed, even when there is only a slight chance of survival. Thus, unilateral decisions by emergency physicians to withhold CPR are only justified in special cases when it is obvious that CPR and preservation of life would not be in the patient's interest. When in doubt, resuscitation attempts must be made. The futility of these efforts may emerge later in hospital, or information becomes available regarding the patient's will which justifies an end to therapy.