Decisions on cardiopulmonary resuscitation

The interruption of the supply of oxygen to the brain in acute cardiac arrest requires immediate action. In the acute situation, it is particularly difficult to assess the individual prognosis, and frequently the patient’s wishes are not available, not clear or not documented. As a result, conflicts may arise between medical professionals’ duties to save life, to do no harm, and to respect the patient’s autonomy. For relatives, it is often highly stressful to have to make a decision on the patient’s behalf. All parties may thus be confronted with a situation in which CPR is performed and it subsequently transpires that these measures were not appropriate or not desired.

To support medical professionals, the SAMS previously issued medical-ethical guidelines in 2008. These were comprehensively revised in 2021, taking into account both medical and social developments, as well as the latest scientific findings. To ensure that the revision was based on the most recent data available, the SAMS commissioned Cochrane Switzerland to prepare an evidence synthesis on prognostic factors.

The revised guidelines offer recommendations as to the situations where CPR is appropriate and when such measures are not indicated. Guidance on the procedure to be adopted in the various (in- and out-of-hospital) situations where acute cardiac arrest may occur should facilitate decision‑making in individual cases. In addition, the guidelines offer support for medical professionals discussing CPR with patients and relatives, and include recommendations on aftercare for resuscitated patients.

According to the guidelines, the outcome of CPR is not to be evaluated merely on the basis of whether return of spontaneous circulation (ROSC) is attained and the patient survives to hospital discharge. What is crucial is that the patient should survive without severe neurological sequelae and with a (subjectively) good quality of life. Neurological status is to be described using the Cerebral Performance Categories classification. However, the CPC criteria do not encompass all possible late effects. An important additional factor in evaluating the outcome of CPR is the patient’s subjective experience and satisfaction with the (new) situation.

Assessment of the prognosis is extremely difficult. While statistical information is available on specific patient groups, this often does not allow precise conclusions to be drawn about particular cases. To predict the outcome of CPR, scoring systems which quantify pre-existing impairments and/or illnesses are used in some cases. The chances of surviving cardiac arrest without significant health deficits remain low. In recent years, however, there has been an increase in the proportion of successful resuscitations, with a good neurological outcome. This is largely attributable to three factors: (1) improvements in the so-called chain of survival, (2) a better knowledge of unfavourable prognostic factors, and (3) the fact that the topic has become less of a taboo, so that patients’ wishes are increasingly being determined and documented, and CPR is less frequently attempted when the outcome is likely to be unfavourable.

According to the guidelines, CPR offers little or no likelihood of benefit in cases where, prognostically, a short- or medium-term extension of life, with a (subjectively) tolerable quality of life, can almost certainly be ruled out.

As mentioned in the guidelines, significant sex-related differences exist. For example, studies report poorer long-term survival in women suffering out-of-hospital cardiac arrest. This is attributable to various (modifiable) factors, such as the fact that women undergo invasive diagnostic procedures less frequently than men and also less often receive pharmacological treatments or ICU therapy.

Advanced age and frailty are prognostic factors. Even though an age limit is specified in the guidelines, this is given merely for guidance, to be taken into account in individual cases. For the assessment of frailty, various scales are available, each with its own advantages and disadvantages. In general, SAMS guidelines recommend the use of the Rockwood Clinical Frailty Scale (CFS), which was developed for adults over 65 years of age. Here, too, however, what is decisive is the individual prognosis.

Advanced age, comorbidities and also frailty increase the likelihood of cardiac arrest. When an initial situation of this kind exists, if not earlier, it is appropriate to raise the question of a CPR decision – e.g. as part of advance care planning – and to document the patient’s wishes in a legally valid form. To permit a realistic assessment of the prognosis, an advisory discussion with a professional is recommended. Patients may, however, formulate their wishes without expert support and record them in a document with legal force, e.g. an advance directive. For an individual risk-benefit assessment and to facilitate the decision on CPR status, a discussion between the patient or authorised representative, relatives and a medical professional can be helpful. A decision, even when it has been recorded, may be modified at any time by a patient with capacity. This in turn should be appropriately documented.

The requirement for explicit consent to treatment is essentially also applicable for CPR. As a patient suffering cardiac arrest lacks capacity, it is not possible to obtain informed consent at this point. In an urgent case of this kind, according to Art. 379 of the Swiss Civil Code, the physician is entitled to carry out medical procedures in accordance with the presumed wishes and interests of the person lacking capacity. If the (presumed) wishes are known, all measures are to be guided thereby. If circumstances (time pressure, cardiac arrest site, etc.) so permit, the emergency medical team must look for any evidence that would indicate the patient’s (presumed) wishes. If the person concerned rejects CPR, it must not be performed. If it is not possible to ascertain the patient’s (presumed) wishes, his/her interests are the decisive factor. In this situation, the patient’s life is to be preserved if possible, but CPR is to be withheld if it offers little or no likelihood of benefit.

DNAR (Do Not Attempt Resuscitation) symbols – e.g. stamps applied to the skin each day or «No CPR» necklaces – do not have the same legal force as an advance directive, the validity of which is assured by the Swiss Civil Code. Such symbols do, however, provide strong evidence of the patient’s (presumed) wishes, and the emergency medical team may be guided by this in the emergency situation and withhold CPR. A stamp represents a marking «in the author’s own hand» since – if applied each day after showering – it bears the day’s date and thus expresses the patient’s current wishes. There may, however, be situations where, in the circumstances, the emergency medical team doubts whether a symbol actually reflects the patient’s wishes (for instance, when close relatives provide a credible assurance that the wishes of the person concerned have changed). In this situation, the emergency medical team will initiate CPR.

If it only becomes apparent after the initiation of CPR that this does not accord with the patient’s (presumed) wishes – for example, in the light of an advance directive or credible information provided by authorised representatives and/or relatives – then the CPR efforts must be terminated. Even if, at this point, return of spontaneous circulation (ROSC) has already been attained, the measures must be guided by the patient’s (presumed) wishes.

As stated in the guidelines, the measures already initiated (e.g. intubation, ventilation) are to be continued until hospital admission, but no additional strictly resuscitative measures are to be performed and, in the event of a renewed cardiac arrest, no further CPR is to be undertaken. If the patient then continues to require ventilation, this is to be terminated and the aim of treatment should be purely to alleviate symptoms. It is to be assumed that patients who have rejected CPR in order to avoid the long-term risks (e.g. neurological damage) would not change their wishes in this situation. The crucial point (also from a legal perspective) is that, in the post‑ROSC situation, the risks of long-term damage, which the patient wishes to avoid by refusing CPR, still exist.

The decision on CPR status and its documentation in the patient’s records are of great significance. Each decision must therefore be based on the fundamental ethical values of good medical practice, which include respect for human autonomy and respect for the principles of beneficence and non-maleficence. These entail a duty to preserve a patient’s life if possible, but also to withhold CPR efforts if they offer little or no likelihood of benefit. The guidelines state that it is not ethically justifiable to perform CPR offering little or no likelihood of benefit, as this would impose an unnecessary burden on the patient and merely prolong the dying process.

The question of resuscitation may also arise during the medical transport of a patient. The partly controversial view that resuscitation should systematically take place during such transport, in the absence of a valid advance directive stating the contrary, is not tenable. It is worth examing such cases carefully, as the legal situation between the patient and the healthcare professional may differ. Regina Aebi-Müller, member of the Central Ethics Committee of the SAMS, and Sarah Wildi have published an informative article on this subject.