“Futility” is a word which means the absence of benefit. It has been used to describe an absence of utility in resuscitation endeavours but it fails to do this. Futility does not consider the harms of resuscitation and we should consider the balance of benefit and harm that results from our resuscitation endeavours. If a resuscitation is futile then any harm that ensues will bring about an unfavourable benefit/harm balance. However, even if the endeavour is not futile, by any definition, (...) the benefit/harm balance may still be unfavourable if the harms that ensue are great.It is unlikely that we will ever achieve a consensus definition of futility and certainly not one that is applicable to every patient undergoing resuscitation. In the meantime our use of the term “futile”, in the mistaken belief that it tells us whether it is worth resuscitating or not, has no utility as it will never succeed in telling us this. Furthermore we risk causing offence by use of the term and we risk harming the patient's autonomy by using futility as an overriding force. Instead we should consider the utility of our endeavours, for which an assessment of the harms of resuscitation should be added to our considerations of its benefit. This balance of benefit and harm should then be evaluated as best it can be from the patient's perspective. The words futile and futility should be abandoned by resuscitationists. (shrink)

This essay explores the unique perspective of medical students regarding the ethical challenges of providing full disclosure to patients and their families when medical mistakes are made, especially when such mistakes lead to tragic outcomes. This narrative underscores core precepts of the healing profession, challenging the health care team to be open and truthful, even when doing so is uncomfortable. This account also reminds us that nonabandonment is an obligation that assumes accountability for one’s actions in the healing relationship and (...) that apologizing for mistakes can serve to heal. It argues that even medical students have an obligation to speak up when actions violate their moral beliefs, even if this means confronting a superior. Ethical principles cannot be abandoned in fear of adverse evaluation or failure to conform. Healthcare workers have an obligation to address mistakes made around the time of a patient’s death with the patient’s family. This responsibility trumps any selfish desire to avoid unpleasant feelings of guilt or regret. Such events often bring closure to already anguished relatives and spouses, and may help to facilitate the grieving process. This includes pressing forward the need to apologize to patients and/or their families when mistakes are made and when decisions are made that lead to poor outcomes for the patient, even when benevolently intended. (shrink)

The urgency of the resuscitation and the impaired ability of the patient to make a reasonable autonomous decision both conspire against adequate consideration of the principles of medical ethics. Informed consent is usually not possible for these reasons and this leads many to consider that consent is not required for resuscitation, because resuscitation brings benefit and prevents harm and because the patient is not in a position to give or withhold consent. However, consent for resuscitation is required and the common (...) models employed for this purpose are presumed consent or consent from a patient proxy. However, if we are to honour the principles of respect for patient autonomy, as well as beneficence and non-maleficence, when starting and continuing resuscitation we must try and achieve the best balance between benefit and harm from the patient's perspective. The concept of professional substituted judgment involves the resuscitators gathering as much information about the patient as they possibly can, including any previously expressed attitudes towards such a situation, and combining this with their acquired professional knowledge of the likely benefits and harms of the resuscitation endeavour and then exercising their moral imagination, imagining themselves as the patient, and asking "would I want this treatment?" By employing professional substituted judgment resuscitators should recognise when the balance of benefit and harm becomes unfavourable from the patient's perspective and at this point they have a moral obligation to withdraw resuscitation as they can no longer presume the patient's consent. In this way the principles of beneficence, non-maleficence and respect for patient autonomy are more favourably balanced than under other resuscitation decision making processes. (shrink)

I read Dr Cherniack’s article regarding do not resuscitate orders with interest.1 One of the problems with DNR orders is the patients’ assumption that if there is no DNR order they will survive resuscitative efforts. This of course is far from the truth. In my hospital these orders have been modified to “do not attempt to resuscitate” orders. One cannot be truly autonomous without being informed. Long term survival, as measured only by being alive, following inhouse cardiac arrest, is about (...) 15% over all age groups.2 In sick elderly patients over 70 years of age who survive a cardiac arrest, the subsequent hospital mortality approaches 100%. This fact, and concerns about harm, influence physicians’ attitudes, …. (shrink)

Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics (...) consult outcomes were analyzed. In 42 of the 116 cases, the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying. The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants’ recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients. (shrink)

On one view, limb transplants cross technological frontiers but not ethical ones; the only issues to be resolved concern professional competence, under the assumption of patient autonomy. Given that the benefits of limb transplant do not outweigh the risks, however, the autonomy and rationality of the patient are not necessarily self‐evident. In addition to questions of resource allocation and informed consent, limb, and particularly hand, allograft also raises important issues of personal identity and bodily integrity. We present two linked schemas (...) for exploring ethical issues in limb transplants. The first, relying on conventional concepts in biomedical ethics, asks whether the procedure is research or therapy, whether the costs outweigh the benefits, and whether it should be up to the patient to decide. The second introduces more speculative and theoretically challenging questions, including bodily integrity, the argument from unnaturalness, and the function of the hand in expressing personal identity and intimacy. We conclude that limb transplants are not ruled out a priori, unlike some procedures that are prima facie wrong to perform, such as amputation of healthy limbs to relieve body dysmorphic disorders. However, their legitimacy is not proven by appeals to the interests of scientific research, cost‐benefit, or patient autonomy. (shrink)

Some health care organizations allow physicians to withhold cardiopulmonary resuscitation from a patient, despite patient or surrogate requests that it be provided, when they believe it will be more harmful than beneficial. Such cases usually involve patients with terminal diagnoses whose medical teams argue that aggressive treatments are medically inappropriate or likely to be harmful. Although there is state-to-state variability and a considerable judicial gray area about the conditions and mechanisms for refusals to perform CPR, medical teams typically follow a (...) set of clearly defined procedures for these decisions. The procedures are based on the principle of nonmaleficence and typically include consultation with hospital ethics committees, reflecting the guidelines of relevant professional associations. Ethical debates about when CPR can and should be limited tend to rely more on discussions of theory, principles, and case studies than systematic empirical study of the situations in which such limitations are applied. Sociologists of bioethics call for empirical study, arguing that what ethicists and health professionals believe they are doing when they draft policies or invoke principles does not always mirror what is happening on the ground. In this article, we begin the task of modeling the empirical analyses sociologists call for, focusing on a cohort at Massachusetts General Hospital. We inductively analyzed ethics committee notes and medical records of nineteen patients whose surrogates did not accept the decision to withhold CPR. (shrink)

SIRThere are some important flaws in Michael Ardagh's reasoning.11. Cardiopulmonary resuscitation is a “blanket term” for different interventions. Curative and supportive treatments have different ethical contexts and cannot be discussed at the same level. It is imperative to ascribe curative interventions within CPR the same status as any other curative intervention, such as antibiotics for infections or surgery for appendicitis. Then we will be able to discuss the ethical context of purely supportive measures such as chest compressions. To address the (...) “ethics of CPR” is a dangerous misnomer.The preferences of emergency personnel2 suggest the willingness to undergo curative interventions early during CPR, but not protracted supportive interventions. Conversely, withholding curative interventions during CPR should only be considered when any curative treatments would also be withheld.2. Cardiopulmonary resuscitation is performed to offer the patient a benefit. However, CPR as a whole is only marginally effective. …. (shrink)