Preventing harm in resuscitation medicine

Abstract

Assumptions regarding urgency and impaired patient competence during resuscitation have left resuscitation medicine relatively free of the influence of medical ethics. As a consequence resuscitators are without clear guidance during decision making. The aim of this thesis is to develop an applicable model for ethical deliberation during resuscitation, and in so doing, to minimize the harms of resuscitation.

During resuscitation urgency and impaired patient competence conspire against an adequate consideration of the principles of biomedical ethics espoused by Beauchamp and Childress. The alternative to resuscitation, when resuscitation is indicated, is usually death. Consequently, it is generally perceived 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. These perceptions have encouraged the use of the terms 'withholding', 'withdrawing' and 'futility', each of which is counter to good decision making during resuscitation. However, these perceptions are wrong. Resuscitation may not bring benefit, or its benefit may be limited. It may cause a great degree and variety of harms, and the patient is in a position where some forms of consent are applicable.

To minimise the harms of resuscitation, and to maximise the respect for the principles espoused by Beauchamp and Childress, we should employ the model of presumed consent with professional substituted judgement. This involves the resuscitators gathering as much information about the patient as they can, and with their acquired professional knowledge of the likely outcome of the resuscitation, the resuscitators can then exercise their moral imagination by imagining themselves as the patient, with the patient's condition and values system, and asking "would I want this treatment?" If the answer to the question is, "No, I would not", then the resuscitation should not proceed. To resuscitate without regard for the patient's perceived wishes is a harmful disrespect for the patient's autonomy.

Often, a decision to proceed will be made on the basis of an uncertain balance of benefit and harm, and an alternative of certain death if resuscitation is not undertaken. Furthermore, the perception of the harms and benefits from the patient's perspective may be unclear and under such circumstances it is appropriate to give the patient a trial of treatment. However, the balance is dynamic, with a clearer view of the likely benefits and harms emerging as the patient responds or does not respond to resuscitation endeavours, and therefore the question must be re-considered. As soon as the answer becomes, "No I would not want this resuscitation," then the resuscitation must stop, as the resuscitators can no longer presume the patient's consent. In this way the patient's autonomy is resurrected and the principles of beneficence and non-maleficence are favourably balanced.