A survey of key opinion leaders on ethical resuscitation practices in 31 European Countries

doi:10.1016/j.resuscitation.2015.12.010

Resuscitation

Volume 100, March 2016, Pages 11-17

https://doi.org/10.1016/j.resuscitation.2015.12.010 Get rights and content

Abstract

Background

Europe is a patchwork of 47 countries with legal, cultural, religious, and economic differences. A prior study suggested variation in ethical resuscitation/end-of-life practices across Europe. This study aimed to determine whether this variation has evolved, and whether the application of ethical practices is associated with emergency care organisation.

Methods

A questionnaire covering four domains of resuscitation ethics was developed based on consensus: (A) Approaches to end-of-life care and family presence during cardiopulmonary resuscitation; (B) Determinants of access to best resuscitation and post-resuscitation care; (C) Diagnosis of death and organ donation (D) Emergency care organisation. The questionnaire was sent to representatives of 32 countries. Responses to 4-choice or 2-choice questions pertained to local legislation and common practice. Positive responses were graded by 1 and negative responses by 0; grades were reconfirmed/corrected by respondents from 31/32 countries (97%). For each resuscitation/end-of-life practice a subcomponent score was calculated by grades’ summation. Subcomponent scores’ summation resulted in domain total scores.

Results

Data from 31 countries were analysed. Domains A, B, and D total scores exhibited substantial variation (respective total score ranges, 1–41, 0–19 and 9–32), suggesting variable interpretation and application of bioethical principles, and particularly of autonomy. Linear regression revealed a significant association between domain A and D total scores (adjusted r² = 0.42, P < 0.001).

Conclusions

According to key experts, ethical practices and emergency care still vary across Europe. There is need for harmonised legislation, and improved, education-based interpretation/application of bioethical principles. Better application of ethical practices may be associated with improved emergency care organisation.

Introduction

Cardiac arrest is an unexpected but potentially reversible event and should be distinguished from the expected cessation of cardiorespiratory function as part of natural dying. Survival to hospital discharge following emergency medical service-treated out-of-hospital cardiac arrest is 8–10%.¹ This very low survival rate raises ethical considerations. Equally, significant ethical dilemmas have arisen from the rapid evolution of resuscitation science.² Indeed, as advanced and/or potentially beneficial interventions become widely available and applicable and patient outcomes are improving,¹ defining which patients might benefit from new treatments becomes increasingly important.

Healthcare bio-ethics has evolved as bioethicists endeavoured to accommodate dominant cultural and societal trends.³ However, Europe is a patchwork of 47 countries with legal, cultural, religious, and economic differences. These factors affect how European societies interpret and apply ethical principles in resuscitation and end-of-life care. A previous European survey revealed variation in withholding or withdrawing cardiopulmonary resuscitation (CPR), euthanasia, family presence during resuscitation, death diagnosis by non-physicians, teaching on the recently dead, and communicating a failed resuscitation attempt.²

We sought to determine whether the variation in the practice of resuscitation ethics across Europe has evolved. Furthermore, as emergency care design and organisation also probably varies across Europe, we hypothesised that the level of organisation of emergency care might be associated with the level of application of ethical practices.

Section snippets

Methods

Between February and March 2015 an on-line questionnaire was sent to 40 National Resuscitation Council (NRC) Representatives and/or acknowledged opinion leaders in emergency care from all 32 European countries, where the European Resuscitation Council (ERC) has organised activity [see electronic supplementary material (ESM)]. Questionnaire development was based on co-author consensus, and the principles of autonomy, beneficence, non-maleficence, justice, dignity and honesty.⁴ Co-authors

Results

Responses were originally received from 32/32 countries (100%) and revised Excel datafiles were returned by respondents from 31/32 countries (97%). Only revised data from these 31 countries were included in the final analysis. Respondents provided 73 (99%) of the 74 originally missing data-points. One respondent concluded that he could not answer 6 Domain C questions secondary to regional/local variation in clinical guidelines of healthcare services and/or absence of a specific legal framework.

Discussion

According to national key experts, there is still significant variation in the interpretation of ethical principles across Europe. This is consistent with a previous survey in 2004.² In the 2004 survey, ethical issues referring to euthanasia, withholding/withdrawing of CPR, family presence during CPR, death diagnosis, CPR training on the recently dead, and breaking bad news in 20 European countries were explored.² In the current survey, we highlighted differences in a more organised fashion by

Conclusions

Despite progress in the practices of advance directives and DNAR, our key expert perception-based results are suggestive of persisting substantial variation, primarily in ethical practices and emergency care organisation/access across Europe. This implies a need for harmonisation of national legislations and education-based interpretation and overall improved application of the principles of bioethics, in the presence of a rapidly evolving resuscitation science and technology. Our results also

Contributors

Contributors to the Survey on Ethical Practices: Andres J, Baubin M, Caballero A, Cassan P, Cebula G, Certug A, Cimpoesu D, Denereaz S, Dioszeghy C, Fiser Z, Georgiou M, Gomez E, Gradisel P, Gräsner JT, Greif R, Havic H, Hoppu S, Hunyadi S, Ioannides M, Janusz A, Joslin J, Kiss D, Köppl J, Krawczyk P, Lexow K, Lippert F, Mentzelopoulos S, Mols P, Mpotos N, Mraz P, Nedelkovska V, Oddsson H, Pitcher D, Raffay V, Stammet P, Semeraro F, Truhlar A, Van Schuppen H, Vlahovic D, Wagner A

Author contributions

Study conception and design, critical revision of the manuscript for important intellectual content, and final text approval and assumption of responsibility for the integrity and accuracy of the presented work: All Authors. Data collection: LB and VR. Data analysis: SDM and LB. Data interpretation: SDM, TX, and LB. Drafting of the manuscript: SDM, TX, and LB.

Funding

This study was not funded by any source.

Conflict of interest statement

The authors have no conflict of interest to declare.

Acknowledgements

The authors thank Hilary Phelan and the Office of the European Resuscitation Council for the professional help in the design of the on-line questionnaire, of the dedicated database and for collecting the data.

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The study was based on a cohort of pre-collected data from 2015; as the use of DNACPR decisions has been shown to increase,23 the contemporary prevalence of DNACPR decisions could differ. Generalisability outside of Karolinska University Hospital is limited, as the use of DNACPR decisions is influenced by cultural, religious, and legal factors, as well as regional, and institutional policies.23,24,38,39 For a mixed population of adults admitted through the ED in a Swedish University hospital, frequency of DNACPR decisions was 11%.
The aims were to examine patient and hospital characteristics associated with Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions for adult admissions through the emergency department (ED), for patients with DNACPR decisions to examine patient and hospital characteristics associated with hospital mortality, and to explore changes in CPR status.
This was a retrospective observational study of adult patients admitted through the ED at Karolinska University Hospital 1 January to 31 October 2015.
The cohort included 25,646 ED admissions, frequency of DNACPR decisions was 11% during hospitalisation. Patients with DNACPR decisions were older, with an overall higher burden of chronic comorbidities, unstable triage scoring, hospital mortality and one-year mortality compared to those without. For patients with DNACPR decisions, 63% survived to discharge and one-year mortality was 77%. Age and comorbidities for patients with DNACPR decisions were similar regardless of hospital mortality, those who died showed signs of more severe acute illness on ED arrival. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR decisions, reversal of DNACPR status upon subsequent admission was 32%, with uncertainty as to whether this reversal was active or a consequence of a lack of consideration.
For a mixed population of adults admitted through the ED, frequency of DNACPR decisions was 11%. Two-thirds of patients with DNACPR decisions were discharged, but one-year mortality was high. For patients discharged with DNACPR decisions, reversal of DNACPR status was substantial and this should merit further attention.
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The sudden and unexpected cardiac arrest of a family member can be a grief-filled and life-altering event. Every year many hundreds of thousands of families experience the cardiac arrest of a family member. However, care of the family during the cardiac arrest and afteris poorly understood and incompletely described. This review has been performed with persons with lived experience of cardiac arrest to describe, “What are the needs of families experiencing cardiac arrest?” from the moment of collapse until the outcome is known.
This review was guided by specific methodological framework and reporting items (PRISMA-ScR) as well as best practices in patient and public involvement in research and reporting (GRIPP2). A search strategy was developed for eight online databases and a grey literature review. Two reviewers independently assessed all articles for inclusion and extracted relevant study information.
We included 47 articles examining the experience and care needs of families experiencing cardiac arrest of a family member. Forty one articles were analysed as six represented duplicate data. Ten family care need themes were identified across five domains. The domains and themes transcended cardiac arrest setting, aetiology, family-member age and family composition. The five domains were i) focus on the family member in cardiac arrest, ii) collaboration of the resuscitation team and family, iii) consideration of family context, iv) family post-resuscitation needs, and v) dedicated policies and procedures. We propose a conceptual model of family centred cardiac arrest.
Our review provides a comprehensive mapping and description of the experience of families and their care needs during the cardiac arrest of a family-member. Furthermore, our review was conducted with co-investigators and collaborators with lived experience of cardiac arrest (survivors and family members of survivors and non-survivors alike). The conceptual framework of family centred cardiac arrest care presented may aid resuscitation scientists and providers in adopting greater family centeredness to their work.
European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions
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Therefore, there is a need for interventional, multicentre, randomised, controlled clinical research aimed at reliably assessing the effects of new and potentially beneficial treatments or validating empirical routine practice treatments of uncertain efficacy.63,195,317,318 Striking the best balance between respect for autonomy (i.e. the right to self-determination) and beneficence (i.e. improving patient outcomes) or even non-maleficence (i.e. avoiding patient exposure to unproven treatments) has been recognised as one of the greatest challenges of emergency research conduct.63,195,317,319 The new European Union Clinical Trials Regulation No. 536/2014.
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
Vasopressin and methylprednisolone for in-hospital cardiac arrest — Protocol for a randomized, double-blind, placebo-controlled trial
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To describe the clinical trial “Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest” (VAM-IHCA).
The VAM-IHCA trial is an investigator-initiated, multicenter, randomized, placebo-controlled, parallel group, double-blind, superiority trial of vasopressin and methylprednisolone during adult in-hospital cardiac arrest. The study drugs consist of 40 mg methylprednisolone and 20 IU of vasopressin given as soon as possible after the first dose of adrenaline. Additional doses of vasopressin (20 IU) will be administered after each adrenaline dose for a maximum of four doses (80 IU).
The primary outcome is return of spontaneous circulation and key secondary outcomes include survival and survival with a favorable neurological outcome at 30 days. 492 patients will be enrolled. The trial was registered at the EU Clinical Trials Register (EudraCT Number: 2017-004773-13) on Jan. 25, 2018 and ClinicalTrials.gov (Identifier: NCT03640949) on Aug. 21, 2018.
The trial started in October 2018 and the last patient is anticipated to be included in January 2021. The primary results will be reported after 3-months follow-up and are, therefore, anticipated in mid-2021.
The current article describes the design of the VAM-IHCA trial. The results from this trial will help clarify whether the combination of vasopressin and methylprednisolone when administered during in-hospital cardiac arrest improves outcomes.
Witnessed resuscitation of adult and paediatric hospital patients: An umbrella review of the evidence: Witnessed cardio pulmonary resuscitation
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To examine the research evidence about whether families were allowed to witness cardiopulmonary resuscitation on hospitalised adult and paediatric patients; and the views of patients, families and health professionals, about witnessed cardiopulmonary resuscitation.
An umbrella review methodology of systematic reviews with sufficient methodological quality.
Papers published in Spanish and English between, 1 January 2009 and 31 December 2018 were considered. The following databases were searched: PubMed, CINAHL, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, PsycInfo, Embase, the Central Supplier Database and the Joanna Briggs Institute, Evidence-based Practice Database. Two independent reviewers assessed the papers for methodological quality employing instruments from the Joanna Briggs Institute. Critical appraisal, extraction and synthesis were carried out, employing the established methods for umbrella reviews and the protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO number CRD42019145610).
The search identified 12 systematic reviews with moderate-to-high quality, which covered 110 original papers. Habitually, health professionals expressed controversial views and showed some reluctance to let families be present during cardiopulmonary resuscitation. In contrast, family members felt strongly that they should be present and patients agreed. Key factors that facilitated witnessed cardiopulmonary were a formal institutional policy, educating health professionals, and designating a health professional to support the family. Educational and cultural backgrounds influenced healthcare professionals’ experiences and their attitudes towards witnessed cardiopulmonary resuscitation. In general, Anglo-Saxon countries showed greater support for this practice. These included the United States, which was the country that dominated the literature on this subject.
The best available evidence supports allowing the family to be present during cardiopulmonary resuscitation. It is necessary to include this practice in educational curricula and to train emergency personnel in its implementation. Culturally sensitive policies need to be designed, and the public to be aware of their right to be present.
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The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR.
The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019.
A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001).
During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.12.010.

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Clinical paperA survey of key opinion leaders on ethical resuscitation practices in 31 European Countries☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Contributors

Author contributions

Funding

Conflict of interest statement

Acknowledgements

Resuscitation

Resuscitation

Clin Med

Resuscitation

Resuscitation

Int J Nurs Stud

Resuscitation

Resuscitation

Bioethics at century's turn: can normative ethics be retrieved?

J Med Philos

Principles of Biomedical Ethics

Using the framework method for the analysis of qualitative data in multi-disciplinary health research

BMC Med Res Methodol

On quantitizing

J Mix Methods Res

Unanimity on death with dignity—legalizing physician-assisted dying in Canada

N Engl J Med

Clinical paper
A survey of key opinion leaders on ethical resuscitation practices in 31 European Countries☆