Ethics in Emergency Cardiovascular Care

Kenneth V. Iserson

While the idea of applying ethics to and during cardiopulmonary resuscitation (CPR) may seem daunting, the basic principle is quite easy to understand: the patient’s value system is paramount.

Patient values should guide resuscitation decisions.
In emergency care, adequate information about the patient and the prognosis is required if treatment is to be withheld.
Advance directives and surrogate decision makers are used if the patient lacks decision-making capacity.
A patient’s decision-making capacity is a clinical determination made at the bedside.
Family members may be allowed to observe resuscitation attempts.
Trained personnel must be provided to notify and care for survivors.

Basic Principles

Three ethical issues surround emergency cardiovascular care:

Who makes treatment decisions?
On what basis are these decisions made?
How should clinicians interact with families during and after cardiac resuscitations?

While the idea of applying ethics to cardiopulmonary resuscitation issues may seem daunting, the basic principle is quite easy to understand: the patient’s value system is paramount. It determines his or her goals of therapy and willingness to assume treatment burdens to achieve a certain outcome. The only exceptions are when the patient lacks the capacity to make a decision or when it is not possible to honor his or her treatment requests or when they are not consistent with the possible goals of medicine.

Patient and Societal Values

The patient’s values, which are sometimes expressed through surrogate decision makers or advance directives, incorporate many personal factors, such as religious and cultural beliefs, social relationships, learned behaviors, and self-image. Even though patients may not be able to verbalize the factors they consider in making their health care decisions,
the decisions themselves express their values. In pluralistic societies, clinicians treat multiple individuals with many different value systems, so they must be sensitive to others’ beliefs and traditions.

People learn their values from the culture in which they live, through observation, and through secular (including professional) and religious education. One common source of personal values is organized religion, which helps to mold and maintain societal values. Although various religions may appear dissimilar, most teach the Golden Rule: “Do unto others as you would have them do unto you.” This meshes with, and was probably the source of, commonly accepted secular principles, such as beneficence and nonmaleficence. Problems surface in trying to apply religion-based rules to specific bioethical situations. For example, although the ethical proscription “Do not kill” is generally accepted, interpretations vary on which activities constitute “killing:” active or passive euthanasia, terminal sedation, or other end-of-life palliative medical care.¹

Although each individual is entitled to have a personal system of values, certain values have become generally accepted by the medical community, courts, legislatures, and society at large (Table 37-1). Although some groups disagree about each of the generally accepted values, this dissension has not affected their application to medical care in many western countries.²

Principle of Autonomy (Self-Determination)

Patient autonomy, or self-determination, has long been the overarching professional and societal bioethical value (as well as the key value in health care law). Autonomy recognizes an adult individual’s right to accept or reject recommendations for medical care, even to the extent of refusing all care, if that individual has appropriate decision-making capacity.³ This is the counterweight to the medical profession’s long-practiced paternalism (or parentalism), wherein medical care was based on whatever the practitioner determined was “good” for the patient regardless of whether the patient agreed. Coercion to influence behavior or choice through the force of authority is often coupled with paternalism. The joining of the august figure in white with implied or explicit threats has been and still is a potent force for counteracting any potential patient autonomy. However, the thrust of modern bioethics is to respect patients by honoring their autonomy.²

Health Care Professionals’ Values

CPR and other resuscitation measures should be used only when they may benefit the patient. They should never be used when they merely prolong the dying process. In emergency situations, when information about patients, their wishes, and their medical conditions are unknown, clinicians must assume that resuscitation is warranted until clinical signs demonstrate that further intervention will not be effective.

Health care workers, both in the prehospital arena and in health care facilities, have specific goals for their interventions. Most entered the healing professions to help others, a principle termed beneficence; they dislike intervening when it will not benefit the patient.

Some practitioners have a conflict with specific professional or societal values on a religious, philosophic, or practical basis.⁴ When such a conflict exists in a practitioner’s mind, it is deemed morally and legally acceptable, within certain constraints, for the individual to follow a course of action based on a personal value system. When conflicts between the practitioner’s and the patient’s values exist, however, it is essential for the practitioner to recognize the patient’s identity, dignity, and autonomy and to avoid the
error of blindly imposing one’s own values on another. Even when the physician plans to follow a treatment course consistent with accepted societal values, it is desirable to review the case’s specific circumstances and the hierarchical importance of the values involved. In each case, the ethical analysis must recognize all practicable courses of action and the benefits and detriments of each, while at the same time respecting the patient’s values.⁵

Table 37-1 • Commonly Accepted Societal and Bioethical Values

Autonomy	Self-determination. A person’s ability to make personal decisions, including those affecting personal medical care. Autonomy is the opposite of paternalism.
Beneficence	Doing good. A duty to confer benefits. Production of benefit.
Confidentiality	The presumption that what the patient tells the physician will not be revealed to any other person or institution without the patient’s permission.
Distributive justice	Fairness in the allocation of resources and obligations. This value is the basis of and is incorporated into societywide health care policies.
Nonmaleficence	Not doing harm, prevention of harm, and removal of harmful conditions.
Personal integrity	Adhering to one’s own reasoned and defensible set of values and moral standards.
Privacy	Controlling the extent, timing, and circumstances of sharing oneself (physically, behaviorally, or intellectually) with others.
Source: Adapted from: Iserson KV. Bioethics. In Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed. Philadelphia: Mosby, 2006:3127–3139, with permission.

For emergency cardiovascular care, the key to this analysis is to recognize that the goals are to preserve life, restore health, relieve suffering, limit disability, and reverse clinical death.⁶ CPR and other resuscitation measures should be used only when they may benefit the patient. They should never be used when they merely prolong the dying process. “Benefit” means attempting to meet the patient’s goals of therapy. In emergency situations, when information about patients, their wishes, and their medical conditions are unknown, clinicians must assume that resuscitation is warranted until clinical signs demonstrate that further intervention will not be effective.

Patient self-determination may not apply when insufficient resources exist to provide the desired intervention. This often occurs in disasters and in less developed nations. In these situations, the ethical principle of comparative, or distributive, justice comes into play. Health care policy based on this principle requires that individuals and groups with similar problems should receive similar (generally an equitable, not necessarily an equal) distribution of available resources. Such a public health policy should be triggered by specific events; it should not be applied ad hoc by individual clinicians at the bedside.²^,⁷

Clinicians often attempt to use legal justifications for their actions or inactions in end-of-life care, including cardiac resuscitation. In general, physicians’ legal knowledge is often incorrect, only partially true, or applied incorrectly.⁸ Patients and health care providers are best served if the patient’s values and goals of therapy guide the physician’s course of action.

Withholding and Withdrawing CPR

Differing levels of knowledge about patients, their medical conditions, and their desire for resuscitation require the use of separate approaches to withholding and withdrawing CPR in the prehospital, emergency department, and inpatient settings. Inpatients may also have ongoing treatments withdrawn.

Prehospital Considerations

Bystander CPR

In the prehospital setting, what is known about patients in cardiopulmonary arrest can vary greatly depending upon the setting and the nature of bystanders’ knowledge. Given the general paucity of facts and the wide range of skill levels among those who may be in a position to initiate CPR, the standard for withholding life-sustaining treatments in the prehospital setting is much higher and more specific than that for other settings. Based on the assumption that most people in cardiopulmonary arrest would want resuscitation, lay-rescuers and bystanders normally should initiate CPR. There are only three exceptions to this rule: (1) when a person has obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, injuries incompatible with life, decomposition, or burned beyond recognition), (2) when performing CPR would place the rescuer at risk, and (3) when an available and interpretable advance directive specifies that the individual does not desire resuscitation.⁶ Advance directives may not apply in cases of a failed suicide attempt.⁹^,¹⁰^,¹¹

Resuscitative efforts should not be withheld or withdrawn on the basis of DNAR (do not attempt resuscitation) tattoos or other nonstandard requests that do not involve discussions with patients or their legal surrogate decision makers.¹²^,¹³ They should also not be withheld or withdrawn based on the patient’s age, socioeconomic status, insurance coverage, cultural background, or relationship to the criminal justice system.

Having begun, those performing CPR should continue until one of the following occurs:

Effective, spontaneous circulation and ventilation are restored.
Care is transferred to a more senior-level emergency medical professional.
Reliable criteria indicating irreversible death are present.
The rescuer is unable to continue due to exhaustion or the presence of dangerous environmental hazards or because
continuation of resuscitative efforts places other lives in jeopardy.
A valid and interpretable DNAR order is presented to rescuers.⁶^,¹⁴

Emergency Medical Services

Emergency medical services (EMS) providers have a higher level of training and more experience than lay-people, resulting in a greater awareness of when to refrain from resuscitative efforts. EMS providers may also have the emotional distance and clinical expertise to know when to stop CPR. The ability to provide advanced cardiac life support (ACLS) interventions, do electrocardiograms, and contact a base station for medical direction helps them make these decisions. However, neither lay-rescuers nor EMS personnel should make judgments about the present or future quality of life of a cardiac arrest victim on the basis of current or anticipated neurologic status. Such snap judgments are often inaccurate. Quality of life should never be used by EMS personnel as a criterion to withhold CPR, because conditions such as irreversible brain damage or brain death cannot reliably be assessed or predicted.¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹^,²⁰

EMS Termination of Resuscitation Efforts

The most powerful discriminatory criterion on the appropriateness of CPR is knowledge of the time of onset of CPR (i.e., witnessed cardiac arrest).

When, then, should EMS personnel cease resuscitative efforts? Although there are no scientifically valid clinical criteria that accurately predict the futility of CPR, the most powerful discriminatory criterion on whether CPR is appropriate are whether the cardiac arrest was witnessed and whether the rescuer knows the time of onset of the arrest.²¹^,²²^,²³^,²⁴^,²⁵ Most commonly, patients with an unwitnessed cardiac arrest are persons who died and were later discovered.²⁶ Another useful criterion to cease CPR is the absence of a “shockable” rhythm on the defibrillator after an adequate trial of CPR, even if ACLS providers are not available.⁶

The American Heart Association (AHA) has affirmed that “emergency transportation of patients requiring continuing CPR after ACLS-level care in the field is rarely indicated or successful. Any such transportation for reasons other than to benefit the patient is unethical.”²⁶ Unless patients are suffering from rare, specific pathologic conditions (e.g., hypothermia or drug overdose), there are no in-hospital interventions that will successfully resuscitate those who fail out-of-hospital efforts.²⁷ Studies have consistently shown that <1% of patients who continue to receive CPR while being transported to the hospital will survive to hospital discharge, but EMS personnel in the United States continue to transport them, usually “Code 3,” posing an unnecessary risk to themselves and others.⁶^,²²^,²⁴^,²⁸^,²⁹^,³⁰ This may be due to rules within the EMS system or to their discomfort with having to stop efforts in a victim’s home, which they may see as publicly acknowledging “failure.”³¹ In addition, both family and EMS personnel are often uncomfortable in leaving a body at the scene.

To end these unnecessary, wasteful, and potentially dangerous transports, it is vital that EMS systems establish protocols for death pronouncement in out-of-hospital settings in a manner consistent with state and national regulations. The AHA, American College of Emergency Physicians (ACEP), and National Association of EMS Physicians support this.³¹ Even where a death pronouncement protocol exists, there may be significant variability among base hospitals in the rate with which they pronounce deaths using online medical control.³⁰ Additionally, even with protocols in place, paramedics may be reluctant to terminate resuscitation efforts in children in the prehospital setting.³²

Emergency Department

In emergency medicine, a significant difference rightfully persists between the withholding and the withdrawal of life-sustaining medical treatment. The justification for this stems in part from the nature of emergency medical practice and the unique manner in which clinicians apply many ethical principles. Because emergency physicians often lack vital information about their patients’ identities, medical conditions, and goals for medical treatment, withholding emergency medical treatment is more problematic than is later withdrawing unwanted or useless interventions. Owing to the nature of emergency medicine, both in the prehospital and the emergency department settings, higher standards are required to withhold than to withdraw medical treatment.³³

Physicians should begin or continue resuscitation of those patients who arrive at the emergency department without sufficient evidence to determine that the resuscitation
effort will be unsuccessful. The only reason to withhold CPR is when the physician has clear evidence (e.g., a standard advance directive) indicating that the patient did not wish this done. Without this information, the presumption must be to intervene.

The only reason to withhold CPR is clear evidence (e.g., a standard advance directive) indicating that the patient did not wish resuscitation to be initiated.

Once the emergency physician obtains information confirming a patient’s wish not to be resuscitated or about a medical condition not amenable to resuscitation, resuscitative efforts and other medical treatment may appropriately be withdrawn. This information may be obtained from an advance directive, patient surrogate, recent documentation in the medical chart, or medics detailing the failed results of the ongoing resuscitative effort. With rare exceptions, such as after failed suicide attempts, resuscitative efforts should be withdrawn when information is provided either that the patients did not want such efforts or that their medical condition precludes success.¹¹^,¹⁴

Many factors influence the potential success of resuscitative efforts, including time to CPR; time to defibrillation, IV line, and first epinephrine dose; time to insertion of first advanced airway device; comorbid disease; prearrest state; and initial arrest rhythm. No combination of these factors, though, clearly predicts the outcome.²⁶^,³⁴ The most important factor associated with poor outcome is the duration of unsuccessful resuscitative efforts.

The possibility of a successful resuscitation becomes clearer as time progresses: a patient’s chance of being discharged from the hospital alive and neurologically intact diminishes if spontaneous circulation does not return after 10 minutes of intensive resuscitative efforts.²⁰^,³⁵^,³⁶^,³⁷ Malpractice concerns have led some physicians to prolong all resuscitation attempts until they reach the point at which there have been no survivors.²⁶ In reality, cardiac resuscitation with properly executed ACLS interventions and documented asystole should not last >30 minutes and should usually end much sooner except in unusual circumstances, as with prearrest hypothermia, after some drug-induced events, following lightning or electrical shocks, or in infants or children with refractory ventricular fibrillation (VF) or ventricular tachycardia (VT).²⁶^,³⁷^,³⁸^,³⁹^,⁴⁰ Indeed, without these mitigating factors, prolonged resuscitative efforts are unlikely to be successful.⁴¹

Cardiac resuscitation with properly executed ACLS interventions and documented asystole should not last >30 minutes and should usually end much sooner except in unusual circumstances, as with prearrest hypothermia, after some drug-induced events, following lightning or electrical shocks, or in infants or children with refractory VF or VT.

Three special situations should be noted. (1) Cardiac arrest from blunt trauma is nearly uniformly fatal, so there is little benefit from doing chest compressions for any extended length of time after the airway is secured.⁴² (2) When health care resources are limited, as during disasters, available resources (i.e., time, personnel, and equipment) should be devoted to those patients with the greatest chance of benefiting. This may lead to withholding or more rapid discontinuation of resuscitative efforts than is standard in normal practice. (3) It is unethical to prolong resuscitative efforts to practice or teach procedures or to complete research protocols.¹⁴

In the Hospital

In health care institutions, staff generally know or have medical records showing their patients’ medical condition, prognosis, wishes regarding resuscitation, and goals for medical treatment. Resuscitation attempts should be consistent with these goals and medical conditions. As the AHA notes, “It is inappropriate to start CPR when survival is not expected or the patient is expected to survive without the capacity for meaningful human communication.”²⁶ Therefore, CPR should not be instituted when the patient’s vital functions have already deteriorated despite maximal therapy (e.g., as in progressive septic or cardiogenic shock).

CPR should not be instituted when the patient’s vital functions have already deteriorated despite maximal therapy (e.g., as in progressive septic or cardiogenic shock).

In neonates, withholding resuscitation attempts in the delivery room is appropriate when gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors.⁶ This includes not initiating or discontinuing resuscitation in the delivery room of preterm newborns of <24 weeks’ gestation or weighing <500 g, infants whose Apgar score remains zero at 10 minutes,⁴³ and newborns with confirmed or overt lethal malformations and/or chromosomal abnormalities.⁴⁴

In the Hospital: Withdrawal of Ongoing Life Support

The decision to withdraw life support may be made minutes or even decades after the initial resuscitation. Usually it is the result of obtaining additional information from the patient, the discovery of advance directives, or a decision by the surrogate. Often the patient or surrogate requests that interventions be stopped because he or she believes that the “successful” resuscitation has not met the goal of an acceptable result or that the burden to the patient of continued treatment would exceed any benefits. Other reasons to withdraw support include the clinicians’ determination that the interventions cannot ultimately be successful or that the patient is dead by brain criteria, in which case it is no longer technically “life support.”

Goals of Therapy

While withdrawing life-support treatment may be an emotionally difficult decision for family and staff, it is ethically permissible under the circumstances described above. The goal is to avoid prolonging the dying process without degrading the quality of the patient’s remaining life. This practice has widespread ethical and legal support.⁴⁵ Nevertheless, decisions about the withdrawal of artificially provided nutrition and hydration and, less commonly, about other modalities continue to be suffused with religiocultural polemics. If disagreement exists about the course of action, the institution’s bioethics committee or consultant should be called in and, when necessary, asked to mediate between physicians, family, and staff.⁴⁶ In some circumstances, chaplains can effectively intervene, especially when families refuse to allow discontinuation of machines in “brain dead” patients because “a miracle” may occur.

In determining how to limit or withdraw treatments, clinicians and surrogates should carefully consider the patient’s goals for therapy. For example, if a goal is to maintain the patient until loved ones arrive, it may be appropriate to continue mechanical ventilation. In general, interventions that do not contribute to achieving the patient’s goals should be discontinued. Throughout this process, care must continue; comfort measures, including needed analgesics, must never be withdrawn.

Since the initial recommendations for discontinuing ventilator support were published in 1983, withdrawal of ventilators, dialysis, vasopressors, and other life-sustaining treatments has become more common.⁴⁷^,⁴⁸^,⁴⁹ The frequency with which treatments are withdrawn from intensive care unit (ICU) patients before death varies among institutions, with some never withdrawing treatments and others doing so in nearly all eligible patients.⁵¹ It is unclear whether these differences reflect physician or institutional values regarding respecting patient preferences.⁵²

Methods of Withdrawing Treatments

Critically ill patients often have multiple types of life-sustaining treatments. Withdrawing or foregoing these treatments may be done sequentially or simultaneously. The normal sequence in critical care units is to first withdraw dialysis, then to forego further diagnostic workups and discontinue vasopressors. Next, clinicians generally stop intravenous fluids, hemodynamic and electrocardiographic monitoring, and antibiotic treatment. The last interventions to be withdrawn usually are artificial nutrition and mechanical ventilation.⁵²

The rationale for this “stepwise retreat” may not reflect optimal patient care. Rather, the order of withdrawal may relate to the intervention’s symbolic importance, such as artificial feeding, or to how immediately its withdrawal will lead to death, as with a ventilator. Physicians appear reluctant to withdraw interventions that treat iatrogenic problems and are more comfortable withdrawing therapies related to their own subspecialty.⁵³^,⁵⁴ Surrogates are often more willing to eschew new interventions, such as antibiotics or dialysis, because the link between these decisions and death is not as obvious.⁵¹

After a decision to withdraw treatment is made, staff should continue to maintain the patient’s comfort and dignity. Varying symptoms accompany the withdrawal of each life-support intervention. Appropriate therapies should be provided to minimize suffering associated with pain, dyspnea, delirium, convulsions, and other terminal complications. To accomplish this, it is ethically acceptable to gradually increase the dosage of narcotics and sedatives to relieve pain and other symptoms, even to levels that might concomitantly shorten the patient’s life.⁷

For example, methods of withdrawing mechanical ventilation vary considerably among physicians and specialties. With any method, the goal is to keep the patient comfortable using appropriate medications, usually titrated opioids and benzodiazepines. Neuromuscular blocking agents should not be used and, if already in use, should be reversed. To achieve comfort, opioid-tolerant patients may need doses one order of magnitude higher than normal (e.g., 500–1,000 mg/hr). Documentation in the patient chart must specify that this medication is being used for comfort.⁵¹

If a patient has an implanted pacemaker or defibrillator ICD, this should normally be inactivated; although the residual rhythm that will persist is unpredictable, this may prevent automatic and uncomfortable defibrillations from the device at the end of life.⁵⁵ Most modern devices can be made ineffective by noninvasive reprogramming.⁵⁶ Before removing or inactivating such a device, the clinician should inform the patient or surrogate that such action could result in sudden death.⁵⁷

Occasionally, in the process of withdrawing life support, clinicians may need to use terminal sedation (i.e., high doses of sedatives to relieve extremes of physical distress). This is a last-resort clinical response to extreme, unrelieved physical suffering. The purpose of the medications is to relieve suffering, not to intentionally end the patient’s life. While it is an extraordinary measure, withholding such treatment in certain circumstances has been deemed “inhumane.”⁵⁸ Terminal sedation is commonly used in critical care units to treat symptoms of suffocation when mechanical ventilation is withdrawn in dying patients.⁵⁹^,⁶⁰

Decision-Making Capacity, Advance Directives, and Surrogate Decision Makers

Advance directives—such as living wills, durable powers of attorney for health care, and prehospital advance directives—are used to guide a patient’s health care decisions only when they are unable to do so themselves (i.e., when they lack decision-making capacity). When a patient lacking decision-making capacity does not have an advance directive, a surrogate list may be used. The first step for clinicians, however, is to determine a patient’s decision-making capacity at the bedside.

Decision-Making Capacity

In much of western culture, patient autonomy, also called self-determination, is a bedrock principle of modern biomedical ethics as well as law. Justice Benjamin Cardozo codified the principle in 1914 when he wrote that “Every human being of adult years and sound mind has a right to determine what shall be done with his own body….”³ This means that adult patients with decision-making capacity may autonomously make their own health care decisions, including choosing between treatment options, refusing treatment, and designating someone else to make their health care decisions even if they are able to do so themselves. Exercising one’s autonomy is the way to implement one’s own values. In clinical practice, the word “competence” is often used to mean capacity. “Competence” is a legal term and can be determined only by the court.

The capacity to make one’s own health care decisions may vary with the complexity of the decision, such as deciding between invasive or pharmacologic treatment of an arrhythmia or the seriousness of a decision’s outcome, as with a heart transplant. Decision-making capacity can also vary over time. Elderly patients who “sundown” and patients partially incapacitated by drugs or physiologic events such as post–cardiac arrest or transient ischemic attack may not immediately be able to make their own health care decisions, although they may regain this capacity.

Clinicians must often decide whether patients currently have the capacity to make specific health care decisions. It is the treating physician’s responsibility to determine the patient’s decision-making capacity. The process of making this determination should be standardized and the results documented in the patient’s medical record. Simply refusing a physician’s recommendation for a commonly accepted treatment option such as thrombolytics or coronary angiography during an acute myocardial infarction does not, in itself, indicate that the person lacks decision-making capacity.

To have adequate decision-making capacity in any particular circumstance, an individual must understand the options, the consequences of acting on the various options, and the costs and benefits of these consequences, by relating them to a relatively stable framework of personal values and priorities.⁶¹ One simple method, outlined below, for determining decision-making capacity at the bedside is to assess the patient’s responses to three questions.⁶² If any of them cannot adequately be answered, the capacity to make that decision is lacking.

Determining Decision-Making Capacity at the Bedside

After providing a patient with sufficient information to make an informed choice, information about the given condition and prognosis, the nature of the proposed intervention, alternatives, and risks and benefits, the patient is asked:

What options did the clinician present? (e.g., to be hospitalized or not.)
What are the risks and benefits to you for each option?
Why did you select the option you did?

To have decision-making capacity, the patient must provide coherent, appropriate answers to all three questions.

Assessing the last response requires weighing the patient’s answer against what is known about his or her value system. The choice should be accepted if it seems to conform to the patient’s values, even if it is not the choice most people would select (e.g., “I don’t want any more medical treatment” or “I’m not sick enough to go into the hospital”). However, the answer may be bizarre and not consistent with reality (e.g., “They’ll poison me like they do everyone else” or “The voices are telling me not to do it”). Such answers indicate a lack of decision-making capacity. Often, those accompanying the patient may be able to help determine how close the answer is to the patient’s normal value system.²^,⁶¹

It may be especially difficult to evaluate decision-making capacity for patients in the prehospital system via telephone or radio. In these cases, medics can ask the questions and transmit the answers, or the patient can be put on the telephone or radio while the physician asks the questions.

Unconscious patients, such as those in cardiopulmonary arrest, clearly lack decision-making capacity. Unless contradictory information is immediately available, such as a standard prehospital advance directive, consent for resuscitation procedures is presumed.²

Patients who retain decision-making capacity may still prefer to have a health care decision made by someone else. Many cultures, including some within western countries, rely on traditional decision-making models other than patient autonomy; usually this is family- or community-based decision making.⁶³ In those cases, the surrogates must be identified and given the same information the patient would need to make a decision.

When a patient lacks decision-making capacity, an advance directive or surrogate decision maker must be used. A significant number of patients in the hospital and in the acute setting have neither a directive nor an identifiable surrogate. In those cases, the clinician acts as surrogate.⁶⁴

Advance Directives

The term “advance directives” includes several types of legal and quasi-legal documents. Advance directives indicate what medical interventions should be done for a patient in extremis who is no longer able to give or withhold permission for treatment. These forms, signed by the patient or surrogate, are usually written to avoid prolonging an inevitable, often painful or nonsentient dying process. Advance directives are usually variations of a living will, durable power of attorney for health care, or prehospital advance directive. Forms are specific to individual states; forms from other states have legal weight only if state statutes specifically permit it (e.g., Arizona). However, even if they carry no legal weight, these documents can provide caregivers and surrogates with valuable information about
the person’s wishes. State-specific statutes and forms can be obtained from the American Hospital Association, American Medical Association, American Bar Association, and American Association of Retired Persons or their state affiliates, and state governments. Most can be downloaded at no cost from the Internet.

Unfortunately, <50% of all patients needing others to make their health care decisions have advance directives.⁶⁵^,⁶⁶^,⁶⁷^,

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