Withholding Resuscitation in Prehospital Care

Resuscitating people who will otherwise die defines a major mission for emergency medical services (EMS) (1). Having the technical capacity to resuscitate some patients, however, does not mandate attempting it nor ensure its success. As cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) became widespread, clinicians formulated guidelines and policymakers passed laws to direct their appropriate use (2-4).

Clearly, we should not attempt resuscitation if the patient is obviously dead (5). Sometimes, however, we should not attempt resuscitation when it might succeed—when the patient is approaching death and does not want resuscitation (5, 6). For hospitalized patients, we have well-established routines for avoiding unwanted resuscitation: Physicians anticipate the situation, discuss matters with the patient or family, and write orders forgoing resuscitation.

In community settings and hospital emergency departments, clinicians often do not know the patient's wishes, whether for lack of time to ask or lack of routines to ensure that someone asks. For this reason, the American Heart Association (AHA) has long maintained that “except in narrowly defined circumstances … professional first responders are expected to always attempt BLS [basic life support] and ACLS” (7). The AHA's most recent ethical guidelines reiterate this imperative: You must start CPR (6). Although this policy is ethically justifiable (6, 8), emergency medical personnel and bereaved families are often anguished when the circumstances mandate attempts at resuscitation on patients who cannot benefit from the intervention and probably do not want it.

The most ethically justifiable way to reduce inappropriate resuscitation attempts …