Resuscitation decisions

The interruption of oxygen supply to the brain due to circulatory arrest requires immediate action. Assessing the individual chances of success is particularly challenging in the acute situation and the patient's will is often not available, not clear or not documented. Medical professionals can thus be caught in a conflict between the duty to save life, the duty not to harm and respecting the patient's will. For relatives, a proxy decision is often very stressful. Everyone involved may be confronted with the fact that resuscitation measures are carried out and it later turns out that they were not useful or not desired.

To support medical professionals, the SAMS published medical ethical guidelines as early as 2008. These were comprehensively revised in 2021 and take into account current developments and the latest scientific findings. To update the data situation, the SAMS had commissioned Cochrane Switzerland to conduct an evidence synthesis in view of the revision.

The revised guidelines contain recommendations on when resuscitation measures are appropriate and when they are not. Guidelines on how to proceed in different situations of acute circulatory arrest inside and outside the hospital provide orientation for the decision in individual cases. In addition, there is support for the discussion of resuscitation measures with those affected and their relatives, as well as recommendations for the follow-up care of resuscitated persons.

When is resuscitation considered successful?

In assessing the success of resuscitation, the guidelines do not only focus on whether a person's spontaneous circulation (ROSC; Return of Spontaneous Circulation) can be restored and whether they survive until hospital discharge. The decisive factor is that the person can continue to live without serious neurological sequelae and with a good quality of life. To describe the neurological condition, the guidelines rely on the so-called "Cerebral Performance Category". However, these criteria do not include all possible late effects. An important additional factor in assessing the outcome of resuscitation is the subjective experience or satisfaction with the (new) life situation.

How is the prognosis estimated in individual cases?

Estimating the prognosis is extremely difficult. Although there are statistical data on individual patient collectives, these often do not allow precise statements to be made about the individual case. In order to estimate the success of resuscitation, scoring systems are sometimes used that quantify pre-existing impairments and/or diseases. The chances of survival after a circulatory arrest without significant health deficits are still low. However, in recent years, the proportion of successful resuscitations with good neurological outcome has increased. Three factors have contributed significantly to this: 1) the improvement of the so-called "chain of survival", 2) better knowledge of prognostically unfavourable factors and 3) a certain removal of taboos on the subject, which has increased the recording and documentation of the patient's will and decreased resuscitation attempts with an unfavourable outcome.

When is an attempt at resuscitation futile?

According to the guidelines, an attempt at resuscitation is described as futile if it is prognostically highly probable that a short- or medium-term prolongation of life with a tolerable quality of life from the point of view of the person concerned is excluded.

What role do factors such as gender, age, comorbidities play?

The guidelines indicate that there are significant gender differences. According to studies, women who suffer a circulatory arrest outside the hospital have a poorer long-term survival. This has various (remediable) causes, such as the fact that women are less likely than men to receive invasive diagnostics after a circulatory arrest and are less often treated with medication or intensive care. Advanced age and frailty are prognostic factors. Even if an age limit is specified in the guidelines, for example, these are only indications that must be taken into account in individual cases. There are different scales for estimating frailty and each has its advantages and disadvantages. SAMS guidelines usually use the Rockwood frailty scale, which was developed for people aged 65 and over. However, here too the estimated prognosis in the individual case is decisive.

Why is it important to decide early on whether or not you want to be resuscitated in the acute situation of a circulatory arrest?

Advanced age, comorbidities and frailty increase the probability of a circulatory arrest. At the latest when such an initial situation exists, it makes sense to discuss the resuscitation decision - e.g. within the framework of advance health care planning - and to document the will in a legally valid manner. In order to realistically assess the prognosis, a consultative discussion with a specialist is recommended. It is also possible to record one's will in a legally binding way without professional support, e.g. in a living will. A discussion between the person concerned or the legal representative, the relatives and a medical specialist is helpful for an individual risk-opportunity assessment and support for the decision "Yes, Yes, No". Once a decision has been made, it can be changed at any time by the person with capacity. This must be documented accordingly.

What is the orientation of the rescue team in the acute situation of circulatory arrest?

Resuscitation measures also require explicit consent to treatment. Since in the case of circulatory arrest the patient is not capable of judgement, obtaining informed consent is not possible at this point. The Swiss Civil Code states in Art. 379 for this urgent situation that the health care professional will take medical measures according to the presumed will and interests of the incapacitated person. If the (presumed) will is known, all measures must be based on it. As far as circumstances such as time pressure, location of circulatory arrest, etc. permit, the rescue team must look for indications that allow conclusions to be drawn about the (presumed) will of the person concerned. If the person refuses resuscitation attempts, no resuscitation measures may be carried out. If it is not possible to ascertain the (presumed) will, the interests of the person concerned are decisive: life should be preserved if possible, but resuscitation efforts should be refrained from if they are futile.

What is the meaning/obligatory nature of DNAR emblems?

DNAR is the abbreviation of "Do Not Attempt (Cardiopulmonary) Resuscitation". It refers to a person's decision that no resuscitation attempts are desired in the event of circulatory arrest. DNAR emblems such as stamps, which are placed daily on the skin, or necklace pendants express this will. DNAR emblems do not have the same legal force as a living will, the validity of which is legally enshrined in the Swiss Civil Code. However, such emblems are a strong indication of the person's (presumed) will to be respected and the rescue team may rely on them in an emergency situation and refrain from attempting resuscitation. A stamp is a personal drawing, because a stamp applied daily after showering bears the date of the day and thus expresses the current will. However, there may be situations in which the rescue team doubts whether the emblem corresponds to the patient's will due to the circumstances, e.g. if close relatives credibly affirm that the person concerned has changed his or her will. In this situation, the rescue team will initiate resuscitation measures.

What happens if the patient's will only becomes known after resuscitation measures have been initiated?

If it only becomes apparent after the resuscitation measures have begun that they do not correspond to the (presumed) will, e.g. on the basis of an advance directive or on the basis of credible statements by representatives and/or relatives, the resuscitation attempt must be discontinued. Even if a successful return of spontaneous circulation (ROSC) has already occurred at this point, action must be based on the (presumed) will of the person concerned.

The guidelines state that the measures already initiated (e.g. intubation, ventilation) should be continued until the patient is admitted to hospital, but that no additional resuscitation measures should be carried out in the true sense of the word, and that no new and additional resuscitation measures should be carried out in the event of a renewed circulatory arrest. If the patient continues to require ventilation until then, ventilation should be stopped and care should be purely symptom-relieving. It can be assumed that a person who had refused resuscitation because he or she wants to avoid the long-term risks (e.g. neurological damage) will not change his or her will in the situation. The - also legally - decisive point is that after a successful resuscitation of spontaneous circulation, the risks of long-term damage would remain, which the person concerned wants to avoid with their resuscitation veto.

Does it always make sense to initiate resuscitation measures if the person concerned wishes to do so or if his or her will is not known?

The decision Rea-Yes, Rea-No and the corresponding documentation in the patient dossier are far-reaching. Every decision must therefore be based on the ethical principles of good medical practice. These include respect for a person's autonomy and respect for the principles of beneficence and non-harm. These oblige to preserve life if possible, but also to refrain from resuscitation efforts if these are futile. The Guidelines state that it is not ethically justified to perform hopeless resuscitation measures. Hopeless resuscitation measures would unnecessarily burden patients and only prolong the dying phase.

Resuscitation Decisions (2021) PDF