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The study of ethics is the way of understanding and examining the moral life.1 The Hippocratic Oath has been revered as one of the oldest codes of medical ethics. More recently, the American Medical Association Code of Ethics (earliest version in 1847) and the American College of Emergency Physicians Code of Ethics (1997 and 2008) have provided guidance to emergency physicians in application of ethical principles to clinical practice. Most ethical codes address common features such as beneficence (doing good), nonmaleficence (primum non nocere, or “do no harm”), respect for patient autonomy, confidentiality, honesty, distributive justice, and respect for the law. Ethical dilemmas may arise when there is a potential conflict between two principles or values. Ethical dilemmas may be resolved by various means, including individual physician judgment, additional information gathering, and meetings with health care professionals, patients, and families. In some circumstances, the involvement of the institutional ethics committee or the judicial system may be sought.

There are approximately 460,000 sudden deaths in the U.S. annually.2 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 ACLS protocols.

Knowledge of data regarding resuscitation outcomes in various clinical settings is crucial when making evidence-based decisions regarding the risks and benefits of attempting CPR and the duration of resuscitation attempts. Patients who receive early ACLS have improved outcomes.3,4 Patients with presenting rhythms of ventricular fibrillation or ventricular tachycardia have higher survival rates than patients with asystole or pulseless electrical activity. Overall, survival of victims of cardiac arrests to hospital discharge has been estimated in many studies to be between 0% and 10%.4–8

Based on such data, several authors have suggested proposed criteria for withholding resuscitative efforts for patients in certain clinical settings with a low likelihood of successful resuscitation (e.g., unwitnessed arrest, no return of spontaneous circulation in response to ACLS, no shocks delivered, and/or no bystander CPR)9–13 (Table 17-1).

Table 17-1 Factors Predictive of Improved Outcomes after Cardiac Arrest

When considering offering or withholding resuscitative efforts, risks and benefits of resuscitation should be carefully considered. The goal of resuscitative efforts is to restore circulation and life to the patient. Other less tangible benefits may include resolution of guilt of the survivors and the additional time for acceptance of bad news for survivors.

Often, resuscitative measures are undertaken in clinical situations in which physiologic survival is very unlikely. In some situations, there is a substantial risk that if ...

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