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The study of ethics is an effort to understand and examine the moral life.1 The Hippocratic Oath is revered as one of the oldest codes of medical ethics. More recently, the American Medical Association Code of Ethics (earliest version in 1847)2 and the American College of Emergency Physicians Code of Ethics (2016 and 2017)3,4 have provided guidance to emergency physicians in the application of ethical principles to clinical practice. Principles of bioethics include beneficence (doing good); nonmaleficence (primum non nocere, or “do no harm”); respect for patient autonomy, confidentiality, and honesty; distributive justice; and respect for the law. Ethical dilemmas arise when there is a potential conflict between two principles, values, or individuals. Physicians resolve these dilemmas by gathering additional information; assessing patient capacity; conducting meetings with other healthcare professionals, patients, and families; and applying an informed judgment in individual situations. In some circumstances, physicians may seek the involvement of the institutional ethics committee or the judicial system.


There are approximately 300,000 sudden deaths in the United States annually.5 The outcome of resuscitative efforts for victims of cardiac arrest is uniformly poor but varies depending on a variety of factors, including time elapsed since arrest (down time), presenting rhythm, bystander CPR, and response to prehospital advanced cardiac life support protocols. Reported estimates of survival of out-of-hospital arrest vary significantly. Recent data suggest improved survival after cardiac arrest. Overall survival after out-of-hospital cardiac arrest was 5.6% in 2005 to 2006 and improved to 8.3% in 2012.6

Several variables are associated with improved outcome after out-of-hospital cardiac arrest, including witnessed arrest, shockable rhythm, lower age, lack of significant comorbidities, bystander CPR, early advanced cardiac life support early defibrillation, and targeted temperature management.7-19


An advance directive is any proactive document stating the patient’s wishes in various situations should the patient be unable to do so, yet most Americans do not have an advance directive, complicating the application of resuscitative interventions.20-25 See Chapter 301, “Death Notification and Advance Directives,” for further information; see also Chapter 303, “Legal Issues in Emergency Medicine.”

The term futility is subject to interpretation. Healthcare professionals may determine futile interventions to be those that carry an absolute impossibility of successful outcome, a low likelihood of return to spontaneous circulation, a low likelihood of survival to discharge from the hospital, or a low likelihood of restoration of meaningful quality of life. Futility can be defined as “any effort to achieve a result that is possible, but that reasoning, or experience suggests is highly improbable and that cannot be systematically produced.”26 There is no consensus among physicians about the meaning of the term. It is probably more accurate to use terminology such ...

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