The ethics of resuscitation through the eyes of those who actually perform it

Codes of ethics are considered as indispensable parameters of every aspect of medical care. When performing cardiopulmonary resuscitation (CPR) ethical issues become even more important since cardiac arrest (CA) is directly related to death. The aim of this study was to record personal opinions and everyday clinical practice approaches of healthcare professionals (HCPs) regarding ethical issues related to CPR. HCPs answered a questionnaire consisting of 30 questions related to ethical issues in CPR on a voluntary basis. The study included 195 HCPs (88♂& 107♀). Out of the 195 HCPs, 95 were physicians, 71 nurses and 29 paramedics. 49 HCPs (25.1%) worked in the prehospital setting (EMS or Healthcare Centers) and 147 (74.9%) in hospitals. 153 HCPs (78.5%) had previously taken certified resuscitation training courses (CPR-AED, ILS, ALS) and 189 HCPs (96.9%) had participated in resuscitation attempts .Half of them, namely 98 out of 195 (50.2%) believe that CPR should be performed in every case of CA. 112 HCPs (57,4%) reported that this is the common practice in their working environment, whereas 136 (69.7%) stated that there are cases that this approach is not applied. In 68.2% of the cases, physicians make the decision not to attempt CPR, whereas in 25.1% it is a team decision. However, more than half of the HCPs (56.4%) believe that physicians should make that decision. Parameters which should be taken into account when making the decision not to attempt CPR are: preexisting end stage diseases, age of the CA victim, previous functional status and presumed interval between collapse and initiation of CPR. Most of the HCPs, 160 out of 195 (82.1%), do not know the term DNAR, whereas half of them, 105 out of 195 (53.8%), are unaware of the Greek legal system's position to DNAR orders. 109 HCPs (55.9%) believe that relatives should be involved in the decision making process not to attempt CPR and 166 HCPs (85.1%) think that patient's past wishes should be taken into consideration.101 HCPs have performed CPR in front of family members of the CA victim but only 43 (22%) believe that relatives should be present during CPR. The decision of discontinuation of CPR in most of the cases is made by physicians (76,4%), in just a few (2.56%) by paramedics and in some it is a team decision (21%). According to their beliefs, decision to terminate CPR should be guided by duration of CPR attempt, absence of reversible relative causes, not gaining ROSC and anticipated prognosis. 112 HCPs (57.4%) are aware of the term Medical Futility. However, 174 HCPs (89.2%) perform CPR even though they know that the attempt is futile and 177 (90.7%) reported that CPR is performed in their working environment even in futile cases. According to the questionnaire, reasons for this practice are: moral sense (78HCPs-40%), certainty of performing the correct health action (67HCPs-34.3%) and fear of legal consequences (62HCPs-31.8%). Finally, 94 HCPs (48.2%) reported that the quality and duration of CPR attempt is the same independent of its obvious futility. Our results do not only reflect Greek reality but also underline the importance of multifactorial approach, introduce all challenging ethical dilemmas and reveal the inadequate education in ethical issues of resuscitation.