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?


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

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]

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:

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




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”:

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.
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.

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Demystifying Paediatric Resuscitation

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Here is  my presentation for the  Society for Emergency Medicine in Singapore Annual Scientific Meeting (SEMS 2014).


Thanks to Rahul Goswami and SEMS for inviting me over!  I had a great time.

Here are some references for the links and papers I mentioned:


Brown 2002 Emergency Medicine Clinics of North America: dismal prognosis for asystolic arrest.

Leis 2013 Journal of Trauma and Acute Care Surgery: nearly 3% complete neurologic recovery for kids with traumatic asystole. Thanks to Cliff Reid of Resus.ME for this one.

Adult vs children differences

See for a 6-minute overview of my approach to paediatric emergency medicine.

ILCOR Guidelines (Consensus on Science with Treatment Recommendations) 2010: Resuscitation.

Singapore National Resuscitation Council Newborn and Paediatric Resuscitation 2011 Guidelines – Singapore Medical Journal.

Avoiding hyperoxia

Resair 2 study – Saugstad, Pediatrics 1998, cited by a Cochrane review 2005: use room air to resuscitate newborns in the delivery room.

Cold feet in sepsis

Brierley 2009 – Critical Care Medicine: systemic vascular resistance in septic shock can be high or low.
As referenced by the Surviving Sepsis Campaign International Guidelines:
Dellinger 2012 – Critical Care Medicine.   – these international guidelines unfortunately did not consider (or even acknowledge) the results of the FEAST study by Maitland 2011 – NEJM.  See more related references below (Maitland 2013, Kiguli 2014), and Dr Anand Senthi’s discussion on

Dangers of hypotonic fluids

Yung 2009 – Journal of Paediatrics and Child Health

Neville 2010 – Journal of Pediatrics

Limiting radiation exposure

NEXUS paediatric subgroup: Viccellio 2001 – Pediatrics

NICE Head Injury Guideline CG176 (updated January 2014)

PECARN (Head Injury): Kuppermann 2009 – The Lancet

The PREDICT group in Australasia are currently running a prospective study (APHIRST: Australian Paediatric Head Injury Rules Study) comparing a number of decision instruments for head injury in children.

Hall 2004 BMJ: cognitive impairment due to low-dose cranial irradiation.


Evidence-based Vital Signs in children

Fleming 2011 – The Lancet

Cuffed vs uncuffed endotracheal tubes

Weiss 2009 – British Journal of Anaesthesia: RCT showing fewer tube changes with cuffed tubes, no difference in post-extubation stridor

Cricoid Pressure is optional

Good, brief overview by Chris Nickson:

Tournadre 1997 – Anesthesiology: cricoid pressure lowers oesophageal sphincter tone. May actually cause regurgitation…

Walker 2010 – British Journal of Anaesthesia: cricoid pressure compresses and distorts the airway.

Neuhaus 2013 – Pediatric Anesthesia: Only 1 case in 1001 with controlled RSI without cricoid pressure had gastric regurgitation (no pulmonary aspiration).

NODESAT (Apneic Oxygenation) in kids

Weingart & Levitan 2012 – Annals of Emergency Medicine: informative & practical how-to on pre-oxygenation and apneic oxygenation.  Great read!

Rob Bryant 2013 SMACC (PK Talk): kids are not little adults, they are worse (6 min video)

Marianne Gausche-Hill recently presented a summary of the evidence for uses of high-flow nasal cannulae (HFNC) in kids.

Cook et al 1998 – British Journal of Anaesthesia:  illustrated the principle of prolonging the safe apnoea period in anaesthetised kids many years ago.  Apneic oxygenation works in children!

References (full citations)

Brown K, Bocock J.
Update in pediatric resuscitation.
Emerg Med Clin North Am. 2002 Feb;20(1):1-26, v. Review.
PubMed PMID: 11826630.

Leis CC, Hernández CC, Blanco MJ, Paterna PC, Hernández Rde E, Torres EC.
Traumatic cardiac arrest: should advanced life support be initiated?
J Trauma Acute Care Surg. 2013 Feb;74(2):634-8. doi: 10.1097/TA.0b013e31827d5d3c.
PubMed PMID: 23354262.

Saugstad OD, Rootwelt T, Aalen O.
Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair 2 study.
Pediatrics. 1998 Jul;102(1):e1.
PubMed PMID: 9651453.

Tan A, Schulze A, O’Donnell CP, Davis PG.
Air versus oxygen for resuscitation of infants at birth.
Cochrane Database Syst Rev. 2005 Apr 18;(2):CD002273.Review.
PubMed PMID: 15846632.

Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G,
Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Lin J, Lorts A,
Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M, Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R, Schnitzler E, Shanley T, Kache
S, Skippen P, Torres A, von Dessauer B, Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A.
Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.
Crit Care Med. 2009 Feb;37(2):666-88. doi: 10.1097/CCM.0b013e31819323c6.
Erratum in: Crit Care Med. 2009 Apr;37(4):1536. Skache, Sara [corrected to Kache, Saraswati]; Irazusta, Jose [corrected to Irazuzta, Jose]. PubMed PMID: 19325359.

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart
K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee
including the Pediatric Subgroup.
Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
Crit Care Med.2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af.
PubMed PMID: 23353941.

Senthi A
The FEAST Study

Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B, Evans JA, Tibenderana JK, Crawley J, Russell
EC, Levin M, Babiker AG, Gibb DM; FEAST Trial Group.
Mortality after fluid bolus in African children with severe infection.
N Engl J Med. 2011 Jun 30;364(26):2483-95. doi: 10.1056/NEJMoa1101549. Epub 2011 May 26.
PubMed PMID: 21615299.

Maitland K, George EC, Evans JA, Kiguli S, Olupot-Olupot P, Akech SO, Opoka RO, Engoru C, Nyeko R, Mtove G, Reyburn H, Brent B, Nteziyaremye J, Mpoya A,
Prevatt N, Dambisya CM, Semakula D, Ddungu A, Okuuny V, Wokulira R, Timbwa M, Otii B, Levin M, Crawley J, Babiker AG, Gibb DM; FEAST trial group.
Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial.
BMC Med. 2013 Mar 14;11:68. doi: 10.1186/1741-7015-11-68.
PubMed PMID: 23496872; PubMed Central PMCID: PMC3599745.

Kiguli S, Akech SO, Mtove G, Opoka RO, Engoru C, Olupot-Olupot P, Nyeko R, Evans J, Crawley J, Prevatt N, Reyburn H, Levin M, George EC, South A, Babiker AG, Gibb DM, Maitland K.
WHO guidelines on fluid resuscitation in children: missing the FEAST data.
BMJ. 2014 Jan 14;348:f7003. doi: 10.1136/bmj.f7003.
PubMed PMID: 24423891.

Yung M, Keeley S.
Randomised controlled trial of intravenous maintenance fluids.
J Paediatr Child Health. 2009 Jan-Feb;45(1-2):9-14. Epub 2007 Nov 25.
PubMed PMID: 18036144.

Neville KA, Sandeman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL.
Prevention of hyponatremia during maintenance intravenous fluid administration: a prospective randomized study of fluid type versus fluid rate.
J Pediatr. 2010 Feb;156(2):313-9.e1-2. doi: 10.1016/j.jpeds.2009.07.059. Epub 2009 Oct 9.
PubMed PMID: 19818450.

Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR; NEXUS Group.
A prospective multicenter study of cervical spine injury in children.
Pediatrics. 2001 Aug;108(2):E20.
PubMed PMID: 11483830.

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan
P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar
JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of
clinically-important brain injuries after head trauma: a prospective cohort study.
Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0.Epub 2009 Sep 14. Erratum in: Lancet. 2014 Jan 25;383(9914):308.
PubMed PMID: 19758692.

Hall P, Adami HO, Trichopoulos D, Pedersen NL, Lagiou P, Ekbom A, Ingvar M, Lundell M, Granath F.
Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study.
BMJ. 2004 Jan 3;328(7430):19.
PubMed PMID: 14703539; PubMed Central PMCID: PMC313898.

Fleming S, Thompson M, Stevens R, Heneghan C, Plüddemann A, Maconochie I, Tarassenko L, Mant D.
Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies.
Lancet. 2011 Mar 19;377(9770):1011-8. doi: 10.1016/S0140-6736(10)62226-X. Review.
PubMed PMID: 21411136; PubMed Central PMCID: PMC3789232.

Weiss M, Dullenkopf A, Fischer JE, Keller C, Gerber AC; European Paediatric Endotracheal Intubation Study Group.
Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children.
Br J Anaesth. 2009 Dec;103(6):867-73. doi: 10.1093/bja/aep290. Epub 2009 Nov 3.
PubMed PMID: 19887533.

Tournadre JP, Chassard D, Berrada KR, Boulétreau P.
Cricoid cartilage pressure decreases lower esophageal sphincter tone.
Anesthesiology. 1997 Jan;86(1):7-9.
PubMed PMID: 9009934.

Walker RW, Ravi R, Haylett K.
Effect of cricoid force on airway calibre in children: a bronchoscopic assessment.
Br J Anaesth. 2010 Jan;104(1):71-4. doi: 10.1093/bja/aep337. Epub .
PubMed PMID: 19942611.

Neuhaus D, Schmitz A, Gerber A, Weiss M.
Controlled rapid sequence induction and intubation – an analysis of 1001 children.
Paediatr Anaesth. 2013 Aug;23(8):734-40. doi: 10.1111/pan.12213. Epub 2013 Jun 14.
PubMed PMID: 23763293.

Weingart SD, Levitan RM.
Preoxygenation and prevention of desaturation during emergency airway management.
Ann Emerg Med. 2012 Mar;59(3):165-75.e1. doi: 10.1016/j.annemergmed.2011.10.002. Epub 2011 Nov 3. Review.
PubMed PMID: 22050948.

Cook TM, Wolf AR, Henderson AJ.
Changes in blood-gas tensions during apnoeic oxygenation in paediatric patients.
Br J Anaesth. 1998 Sep;81(3):338-42.
PubMed PMID: 9861115.

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