Ethical CPR Decisions

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We spend a lot of time thinking about saving lives, and becoming expert at interventions to maximise survival.  But sometimes we need to take a step back and consider why we are doing this… what are the outcomes we would like to achieve for this patient? For this family?  It may be appropriate to set some boundaries of care.  So how do we go about having this discussion with patients and families?

EMPEM-Hayes-CPR-decisions

We are honoured to be joined by an expert in the field of ethical decision making in CPR, Dr Barbara Hayes.  Join us for a lively discussion as we navigate the perils of talking about death and dying, and the role of CPR.

Apologies for the variable audio quality on this episode.  Hopefully you will still enjoy the discussion.

 


Outline: Ethical decision-making in CPR

Intro [cp]: welcome, disclaimer
[bh]: Barbara Hayes introduction
[cp]: Relevant publication: Hayes B. Clinical model for ethical cardiopulmonary resuscitation decision-making. Internal Medicine Journal. 2013; 43:77-83.
[nl]: Nicole background / interest in ‘dying well’

[bh]: Framework for ethical decisions relating to treatment options

Examples of ethical challenges in CPR decision making:
[nl]: diabetic asthma patient
[bh]: examples from palliative care

Trust:
Sometimes there is a difference of opinion between the patient and family on the one hand, and the treating team on the other hand, about whether CPR should be provided. This is often occurring when the patient is very unwell, and the family are emotional and frightened. How do you work with this?
[nl], [bh], [cp]

Discussion:
Differences in Palliative Care vs ED
Added issues / stressors with dying child

Practical tips for the ‘less experienced’ (ie everyone):

  • Patient first
  • Family (& their grieving) second
  • Think about salvageable quality of life (cf some religious/cultural beliefs re sanctity of life regardless of quality)
  • Be honest in your communication
  • We are the medical experts, family are the expert about the patient (and what they would want, if unable to communicate)
  • Aim to all contribute to the shared pool of understanding, to reach best outcome for the patient
  • What does the patient, family, treating staff want?
  • Use the framework (for any ethical treatment decision, not just CPR)
  • Do not (completely) defer the medical decisions to the family or patient – they need to make an informed decision; guide them when appropriate
  • Remember organ donation as a positive outcome in death

Summary & final ‘take-home’ thoughts:
[cp],[nl],[bh]

Goodbye & invite comments [cp]

 

References and further reading

Hayes B.
Clinical model for ethical cardiopulmonary resuscitation decision-making.
Internal Medicine Journal. 2013; 43:77-83.
PubMed PMID: 22646807

Ehlenbach WJ et al.
Epidemiologic study on in-hospital cardiopulmonary resuscitation in the elderly.
New England Journal of Medicine. 2009; 361: 22–31.
PubMed PMID: 19571280

Hayes B.
Trust and distrust in CPR decisions.
Journal of Bioethical Inquiry. 2010; 7:111-122.

Emanuel EJ & Emanuel LL.
Four models of the physician-patient relationship.
JAMA. 1992; 267(16): 2221-2226 Review.
PubMed PMID: 1556799

 

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Conducting the Orchestra

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empem-orchestra-SEMS-talk

Leading your paediatric resuscitation team effectively.  Another little presentation at SEMS 2014…

 

 

Teamwork

Team size affects task performance in paediatric trauma teams (more than 7 team members results in more delays): Kelleher 2014 Pediatric Emergency Care

Cliff Reid of Resus.ME gives some excellent tips on teamwork & communication, especially regarding influence & persusasion, in his SMACC talk from 2013, “Making Things Happen”:

http://resus.me/smacc-2013/smacc2013-making-things-happen

Essentially: be nice, stay patient-focused, ask for help, and use the group (“we need your help; our plan” etc).

 

Family Presence during resuscitation

Jabre 2013 NEJM - lower rates of PTSD in those relatives randomised to attend resuscitation.

 

References (in full)

Kelleher DC, Kovler ML, Waterhouse LJ, Carter EA, Burd RS.
Factors affecting team size and task performance in pediatric trauma resuscitation.
Pediatr Emerg Care. 2014 Apr;30(4):248-53. doi: 10.1097/PEC.0000000000000106.
PubMed PMID: 24651216.
http://www.ncbi.nlm.nih.gov/pubmed/24651216
Jabre P, Belpomme V, Azoulay E, Jacob L, Bertrand L, Lapostolle F, Tazarourte K, Bouilleau G, Pinaud V, Broche C, Normand D, Baubet T, Ricard-Hibon A, Istria J, Beltramini A, Alheritiere A, Assez N, Nace L, Vivien B, Turi L, Launay S, Desmaizieres M, Borron SW, Vicaut E, Adnet F.
Family presence during cardiopulmonary resuscitation.
N Engl J Med. 2013 Mar 14;368(11):1008-18. doi: 10.1056/NEJMoa1203366.
PubMed PMID: 23484827.
http://www.ncbi.nlm.nih.gov/pubmed/23484827

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