The study of ethics is an effort to understand and examine the moral life.¹ The Hippocratic Oath is revered as one of the oldest codes of medical ethics. More recently, the American Medical Association Code of Ethics (earliest version in 1847)^2,3 and the American College of Emergency Physicians Code of Ethics (1997 and 2008)^4,5 have provided guidance to emergency physicians in the application of ethical principles to clinical practice. Most ethical codes share common tenets such as beneficence (doing good); nonmaleficence (primum non nocere, or “do no harm”); respect for patient autonomy, confidentiality, and honesty; distributive justice; and respect for the law. Ethical dilemmas arise when there is a potential conflict between two principles or values. Physicians resolve these dilemmas by gathering additional information; conducting meetings with other healthcare professionals, patients, and families; and applying an informed judgment in individual situations. In some circumstances, physicians may seek the involvement of the institutional ethics committee or the judicial system.

There are approximately 300,000 sudden deaths in the United States annually.⁶ 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 advanced cardiac life support protocols.

Physicians should consider the patient’s potential outcome including quality of life when initiating a resuscitation effort. Patients who receive early advanced cardiac life support have improved outcomes.^7,8 Patients presenting with ventricular fibrillation or ventricular tachycardia have higher survival rates than patients with asystole or pulseless electrical activity.^9,10 Many studies of cardiac arrest victims have estimated survival to hospital discharge to be between 0% and 13%.^6,8–19 Advanced resuscitative techniques, such as therapeutic hypothermia and advanced cardiac life support protocols, have improved the survival rate for patients with cardiac arrest.⁹

Based on such data, several authors have proposed criteria for withholding resuscitative efforts for patients with a low likelihood of successful resuscitation. Several validated decision rules incorporate related factors predictive of dismal outcome^20–29 (Table 27-1).

When considering offering or withholding resuscitative efforts, the physician must take into account the risks and benefits of resuscitation. The primary goals of resuscitative efforts are to restore the patient’s circulation and, ideally, normal function. Another less tangible benefit may be providing additional time for survivors to accept the distressing news of imminent death of their loved one.

Resuscitative measures are frequently undertaken in clinical situations where physiologic survival with meaningful neurologic function is very unlikely. Patients may be left with significant anoxic brain injury, persistent vegetative state, or dementia with poor quality of life.

Substantial resources are consumed in resuscitative efforts, and clinicians are taken away from other patients (a violation of distributive justice). Another benefit in limiting resuscitative efforts is the freeing of time and resources for family counseling and communication.

The term futility is subject to interpretation.³⁰ Healthcare professionals may determine futile interventions to be those that carry an absolute impossibility of successful outcome, a low likelihood of return to spontaneous circulation, a low likelihood of survival to discharge from the hospital, or a low likelihood of restoration of meaningful quality of life. Futility can be defined as “any effort to achieve a result that is possible, but that reasoning or experience suggests is highly improbable and that cannot be systematically produced.”³¹ There is no consensus among physicians about the meaning of the term. It is probably more accurate to use terminology such as nonbeneficial, ineffectual, or low likelihood of success when discussing resuscitation with patients or families.

Many ethicists agree that physicians are not required to provide treatments that they estimate will provide little or no benefit to the patient.^32,33 The American Medical Association Council on Ethical and Judicial Affairs stated that CPR may be withheld, even if requested by the patient, “when efforts to resuscitate a patient are judged by the treating physician to be futile.”³⁴ Dilemmas regarding nonbeneficial interventions often arise due to inadequate or ineffective communication between the physician, patient, and family. This is of particular concern in emergency medicine, in which previous relationships with patients and family rarely exist and time is often inadequate to establish effective relationships. Thus, initial efforts should be directed to improve communication, education, and joint decision making.

The American College of Emergency Physicians states that “physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of medical benefit to the patient” (Table 27-2). Emergency physicians’ judgments should be unbiased, based on available scientific evidence, mindful of societal and professional standards, and sensitive to differences of opinion regarding the value of medical intervention in various situations.³⁵