Decisions for resuscitation
Resuscitation decisions have their ethical basis in three medical ethical principles that can come into conflict in a concrete decision-making situation.
The principle of care obliges to preserve the life of the patient if possible and is the basis for initiating resuscitation efforts in emergency situations without prior knowledge.
The duty not to harm is the basis for refraining from resuscitation efforts if these would unnecessarily burden the patient.
Finally, the duty to respect the patient's right to self-determination requires refraining from attempts at resuscitation if this is in accordance with the patient's will.
The resuscitation decision requires careful consideration that takes into account the above principles. The most important medical criteria for deciding whether resuscitation measures are indicated or not are the immediate and longer-term chances of survival as well as the expected state of health of the patient after any resuscitation. The initial situation is decisive. It is important whether a cardiovascular arrest occurs as a natural event at the end of life as a result of a serious illness or surprisingly in a previously "healthy" person.
If there is a chance that a patient can continue to live without serious neurological consequential damage from the cardiovascular arrest, an attempt at resuscitation is indicated from a medical point of view. For patients at the end of life, however, resuscitation efforts do not make sense.
The following prognostic factors are relevant for assessing the chances of success in resuscitation efforts. These can only be estimated to a limited extent in advance.
Favourable prognostic factors
- Short interval between the onset of cardiovascular arrest, the start of resuscitation measures and the first defibrillation (observed collapse of the patient).
- Tachycardic heart rhythm disorder (ventricular tachycardia, ventricular fibrillation). This is detected by an AED.
- Good health condition of the patient.
The prognoses listed are also relevant for children and adolescents. In young children in particular, cardiac arrest is often preceded by respiratory arrest. In this situation, the chances of successful resuscitation are high if measures are taken before cardiovascular arrest (assisted or artificial respiration).
Poor prognostic factors
- Confirmed evidence of cardiovascular arrest without effective resuscitation measures for more than ten minutes (after exclusion of hypothermia and without evidence of intoxication).
- Absence of electrical heart action (asystole).
- Pulseless electrical activity (PEA).
- Severe comorbidity and poor previous health status of the patient prior to his cardiovascular arrest.
- Secure knowledge of an immediately life-threatening, non-treatable previous illness.
- Special circumstances of cardiovascular arrest (e.g. polytrauma).
According to current law, there is a general duty to provide assistance in an emergency situation. According to their expertise, doctors and health professionals are subject to higher requirements than medical laypersons. If the will of the person concerned is unknown in the emergency situation and his/her will cannot be ascertained in time, the patient's will to live must be assumed.
However, the patient's will is also obligatory for the attending persons in an emergency situation. If there are clear indications that a person refuses resuscitation attempts, no resuscitation measures may be carried out. If this only becomes apparent in the course of resuscitation efforts, e.g. on the basis of a living will, resuscitation must be discontinued.
In the case of cardiovascular arrest following a suicide attempt, as a rule, a refusal of resuscitation measures may not be concluded on the basis of the suicidal act alone. The history of the suicide, the method, the duration of the suicidal wish, the capacity to judge, etc. require careful consideration. However, this is usually impossible in an emergency situation, which is why resuscitation should be attempted in case of doubt.
- In doubt for life!
- Questions will be asked later!
- An error FOR life is more bearable than an error FOR death!
Failure of resuscitation to be successful:
- >20 minutes of resuscitation without return of cardiac action with spontaneous circulation.
- If a spontaneous cardiac action with circulatory effect occurs again temporarily during resuscitation, the 20-minute resuscitation period starts again.
- The decision should be made by a paramedic or doctor.
Defibrillators that have proven themselves over the years.