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Journal of Medical Ethics 1997; 23: 361-367

Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)
Mark Hilberman, Jean Kutner, Debra Parsons, and Donald J Murphy The Carbondale Clinic, Carbondale,
Colorado, University of Colorado Health Sciences Center, St Joseph's Hospital, and the Colorado Collective for
Medical Decisions, Denver, Colorado, USA

Abstract
Outcomes from cardiopulmonary resuscitation (CPR) remain distressingly poor. Overuse of CPR is attributable to unrealistic expectations, unintended consequences of existing policies and failure to honour patient refusal of CPR. We analyzed the CPR outcomes literature using the bioethical principles of beneficence, non-maleficence, autonomy and justice and developed a proposalfor selective use of CPR.
Beneficence supports use of CPR when most effective.
Non-maleficence argues against performing CPR when the outcomes are harmful or usage inappropriate.
Additionally, policies which usurp good clinical judgment and moral responsibility, thereby contributing to inappropriate CPR usage, should be considered maleficent. Autonomy restricts CPR use when refused but cannot create a right to CPR.
J7ustice requires that we define which medical interventions contribute sufficiently to health and happiness that they should be made universally available. This ordering is necessary whether one believes in the utilitarian standard or wishes medical care to be universally available on fairness grounds.
Low-yield CPR fails justice criteria.
Cardiopulmonary resuscitation should be performed when justified by the extensive outcomes literature; not performed when not desired by the patient or not indicated; and performed infrequently when relatively contraindicated. effective nor benign. Use of this intervention can restore good health and wellbeing to some survivors while the overall benefit to others is low and some are left significantly impaired.
Existing guidelines promote CPR to restore life when cardiac arrest occurs from cardiac causes.'
Statutes which give an implied consent to emergency treatment are used to endorse CPR as the default response to cardiac arrest. It has become common policy to require CPR unless CPR is explicitly refused2 3 or futile.4 Yet, cardiac arrest normally accompanies death and an extensive medical literature supports selective use of CPR.5 6 Cardiopulmonary resuscitation is not an appropriate response to death which occurs as a consequence of advanced age or illness.7 8
Two anecdotes illustrate limitations in the current
Do Not Resuscitate (DNR) approach:

Key words

1. A university hospital cardiac resuscitation team, composed of house physicians, nurses and respiratory therapists, arrived at the bedside of a ninetyyear-old with advanced cancer whose heart had stopped. A DNR order had not been written, and hospital policy required the resuscitation team to proceed with CPR despite their grave medical and moral reservations. An attending physician relieved them of this burdensome policy requirement.
2. A robust 60-year-old was admitted to hospital with vague chest pains for diagnosis and treatment.
After evaluation he was questioned about his CPR preferences, a new conversation promoted by
American laws intended to promote refusal of burdensome life-prolonging interventions. He indicated that he did not wish CPR and a DNR order was written. Within the hour he developed ventricular fibrillation (a treatable, lethal cardiac rhythm disturbance.) Simple electrical defibrillation would have been life-saving. However, the staff felt compelled not to intervene due to the DNR order and were prepared to let him die. Fortunately, his heart spontaneously reverted to a normal rhythm. When asked a second time, the patient changed his mind.

Ethics; bioethics; cardiopulmonary resuscitation; CPR; clinical decision-making; death and dying.

When people are under stress it is unrealistic to

Introduction
Cardiopulmonary resuscitation ordinarily successful. During electrophysiological studies the started, with uniform success.

(CPR) can be extra-

heart surgery and heart is stopped and
Otherwise, recovery from cardiac arrest remains unlikely. Cardiopulmonary resuscitation represents the opportunity for life when cardiac arrest occurs. Yet it remains simply an intervention which is neither intrinsically

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362 Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)

expect consistently sound decision-making. Patients best in the recent literature.2' In other systems the who will not benefit from CPR usually benefit from results are so poor that the whole endeavour should other medical and nursing care. However, a written be reconsidered. Specifically, fewer than 2%
DNR order may represent "giving up" to patients, survive field CPR to hospital discharge in Chicago families and providers. For example, 92% of neurol- or New York, due to traffic-delayed initiation of ogists surveyed indicated that a DNR order for a resuscitation.2223 stroke patient implied withdrawal of other treatment and nutrition. ' Neurologists make the same linkage
Non-maleficence
for patients in a vegetative state.' 0
A CPR paradigm must recognize the complexity We wish to examine the admonition to "do no of the clinical environment and the importance of (deliberate) harm" in terms of outcomes, policies, provider judgment and must respect patient and appropriateness. autonomy. The heart can stop in patients at any age and in conjunction with many underlying illnesses OUTCOMES and the rules should facilitate prompt, effective and The incidence of brain injury following CPR varies appropriate CPR. In this paper we present our from 10-83%.24 28 In one study, 55 of 60 children analysis of CPR issues using the four bioethical prin- died following prolonged field resuscitation; all five ciples of beneficence, non-maleficence, autonomy survivors were in persistent coma or a vegetative state at the time of hospital discharge.27 Many and justice. " patients regard severe disability following significant brain injury as worse than death.29 Cardiopulmonary
Beneficence
resuscitation becomes maleficent when the risk of
Moral agents should take positive steps to help others. brain injury is high.
In medicine this normally involves the restoration of health and function and the relief of pain and suffer- POLICIES ing. These goals were clearly accomplished in the American DNR policies were established to protect early steps towards effective resuscitation: in the late patients from unilateral physician DNR decisions
1 940s and early 50s respiratory intensive care and generally require CPR unless explicitly increased survival in bulbar poliomyelitis from about refused.2 3 Rigid field CPR rules resulted in at least
15% to over 50%.12 13 A decade later, 14 of 20 one dramatic headline: Paramedics rush dead people patients (70%) treated by closed chest cardiac to hospitals, costing millions.30 Since even a relatively massage survived intact.'4 However, investigators brief interruption of blood flow to the brain or heart who followed Kouwenhoven et al at Johns Hopkins results in severe injury, resuscitation can only subsequently reported hospital discharge rates of 14% succeed if applied promptly. Thus, Swedish invesin 1985,'5 and below 10% in 1994.16 The success rate tigators reported that survival exceeded 80% with bystander CPR and ambulance arrival in less than of 70% was never duplicated.5 6
The greatest benefit from CPR, with survival rates two minutes, but was less than 6% with ambulance over 20%, was reported when cardiac arrest occured arrival time over six minutes or no bystander during anaesthesia, from drug overdose, and with CPR.25 Nevertheless, in 1993 it was noted that coronary disease or a primary ventricular arrhyth- Chicago paramedics were required to resuscitate mia.5 6 A 1995 hospital discharge rate of only 17% unless the victim was decapitated, in rigor mortis, or followed CPR in coronary care unit patients, who decomposing.23 In some states, emergency crews are closely monitored and by skilled staff.'7 The are bound to proceed with CPR despite evidence treatment goal is to prevent cardiac arrest, which at the scene that CPR is not wished. In one such frequently represents therapeutic failure and difficult state, 7% of out-of-hospital resuscitations were unwanted.2' disease.
A generation ago moral responsibility was placed
Patients survive CPR infrequently when noncardiac major illness or organ dysfunction precede squarely upon the individual to act appropriately cardiac arrest. Cardiopulmonary resuscitation regardless of orders given. Nevertheless, American survival is extremely poor (