Resuscitating a Patient with No Vital Signs

A 25-year-old man is involved in a motorcycle accident and suffers multisystem trauma. When the paramedics arrive on the scene, the patient has no blood pressure, pulse, or spontaneous respirations. They transport the patient to the emergency de­partment while performing cardiopulmonary resuscitation. The patient has been down at least ten minutes without vital signs.

Patients with blunt trauma, such as motor vehicle accidents, who have no vital signs at the scene, have less than a 1% chance of being resuscitated and eventually leaving the hospital. There is a good chance, however, that the patient could be resuscitated and kept alive long enough to incur large operating room, emergency department, and hospital bills. In addition, while there is a very small chance that this patient could live to leave the hospital, there is a good chance that even if he does, he will have profound brain damage because of the injury already incurred from anoxia.


On the other hand, if extreme measures are not taken, the patient is dead. Extreme measures include opening of the chest, placing several large intravenous lines, via cutdowns, in the patient's extremities, giving multiple units of blood, and attempting to repair any damage. This involves considerable expense, physician time, blood (which is also a limited resource), and nurse and paramedic personnel time.

Commentary

The provision of potentially life-preserving care to a patient whose condition is life-threatening is normally one of the mandates we impose upon emergency care phy­sicians. In an emergency situation, the requirement of obtaining informed consent is waived, because we perceive the provision of the care as a high priority and because we assume that the patient would consent if there were time to consult him and if he were competent.

WITHHOLDING LIFE-PRESERVING TREATMENT


The case we are considering reminds us, however, that a number of reasons have been offered as to why potentially life-preserving interventions might be withheld from patients, in both nonemergency and emergency situations. These reasons are listed in Table.

Table. Reasons for Withholding Life-preserving Intervention.

1. Intervention will not save a life.

2. Intervention will leave an unacceptable quality of life.


3. Intervention is too resource-consuming.


   A. Because society does not want its money wasted.


   B. Because resources needed by other patients might be consumed.


4. Intervention is rejected by the patient.


Care Is Futile


In cases where the care is futile, the physicians recognize that it is highly likely that the patient will die whether or not the intervention is provided and/or that providing the intervention will, at most, only prolong the patient's dying for a short period of time. It is this set of recognitions which we summarize when we say that this intervention is futile and which provides the basis for the withholding of the intervention.


We need to recognize certain ambiguities and borderline cases. How likely must it be that the patient will die anyway before we call the intervention futile? Would only a 10% chance of survival with use of the intervention make that intervention futile? Would only a 5%? Would only a 1%? And how soon must the patient die, even if the intervention works, before we call the intervention futile? Would a month be enough to make it a nonfutile intervention? Would a week? Would a day?

Care Is Pointless


In cases where the care is pointless, the physicians recognize that while the intervention may prolong the life of the patient for a considerable period of time, the quality of the patient's life during that period of time will most probably be very low. It is this set of recognitions which we summarize when we say that this intervention is pointless and which provides the basis for the withholding of the intervention. The ambiguities and the borderline cases are more prevalent here.


Nearly all would agree that intervention is pointless if it is most probable (let's not worry for now how probable that is) that the patient will, at best, survive as a persistent vegetative patient. After that, disagreement abounds. Is the preserving of the stroke victim who can sit and gaze at the world, occasionally recognizing something or someone, a pointless intervention? Is the preserving of the patient with chronic obstructive pulmonary disease, whose every breath is a major effort, a pointless intervention?

Care Is Too Resource-consuming


In cases where the care is too resource-consuming, the physicians recognize that while the intervention may prolong the life of the patient for a considerable period of time, and while the qualify of life during that period of time may be minimally acceptable or even better, the costs of providing the intervention are so high that it cannot be justified in terms of what is gained. There are some who claim that such a decision is never appropriate at the clinical level.

They say that clinicians must provide (within the limits of the resources they have available) the best for the patient, without worrying about whether it's worth it and without even worrying about what this will do for other patients who come later for whom there will be fewer resources available. Questions of resource allocation are, they claim, macrochoices and not clinical microchoices. Others disagree. They claim that either

A. clinicians should make choices of cost effectiveness of care because society, which ultimately pays the bill, does not want its money wasted or

B. clinicians should make such choices in those circumstances in which providing the expensive care now means that later patients will be deprived of care from which they could benefit more, because the resources to provide that later care will not be available.


Naturally, even if one is willing to make either type A or type В clinical decisions, ambiguities and borderline cases abound. For type A decisions, how do we decide how much time at what quality of life is worth how much money? For type В decisions, how certain must we be that providing care now means that we must withhold care later, and how much more must those later patients benefit from that care before we are justified in withholding the current interventions?

Care Is against the Wishes of the Patient


In cases where the care is against the wishes of the patient, the physicians recognize that while the intervention can prolong the life of the patient for a reasonable period of time at reasonable cost, and while the resulting quality of life during that period of time may be minimally acceptable or better, the patient does not wish to have the care provided and would prefer to die rather than to receive the intervention in question.


Naturally, such a wish could be respected only if it were the repeated informed wish of a competent patient who really meant it (rather than using it as a way of calling attention to something else). The ambiguities and borderline cases that arise here result from such questions as: What is it for a patient to be competent? How much information is required for an informed choice? Do hints of denial or unreasonable hope (I can live without this intervention) make it an uninformed choice? How long-standing and re­peated must the decision be before it is to be respected?

DECISIONAL PROCESSES


These four substantive reasons for withholding potentially life-preserving inter­ventions differ not only in their substance but also in the decisional processes which may legitimately invoke them. Type 4 reasons clearly can be invoked only by the patient (and perhaps by those authorized by him to speak in his behalf). At most, the job of the physician is to insure that the patient is competent, informed, and so on.

Type 1 reasons, on the other hand, primarily involve the physician, since the judgments in question are primarily medical. At most, the role of the patient and / or those authorized to speak on his behalf is to concur or disagree with the physician's view as to how dim the prognosis must be for the care to be futile.

Type 2 reasons involve both physicians and patient (or those authorized to speak on his behalf), since the physicians must make judgments about what the quality of life will be while the patient (and / or those authorized to speak on his behalf) must judge whether that is an acceptable quality, a much more significant judgment than the judgment that must be made in type 1 cases.

Finally, cases of type 3, if they ever are legitimate, are cases of pure physician decision making. After all, the reasons in question are reasons for withholding care against the interest of the patient, on behalf of the interests of society or the interests of later patients, and these are not cases of seeking altruistic volunteers, so the patient has no reason to agree. If one is ever justified in making such judgments, it must be with the supposition that it would be against the patient's wishes if he were consulted, and the purpose of consulting him is, at best, unclear.


One final point about this matter of decisional processes. The processes outlined above seem to be the appropriate processes in a world of sufficient time and of sufficient intellectual capacity and strength of mind for those involved to reasonably assess these difficult matters. In the real world, providers, recipients, and / or families often lack one or more of these prerequisites, and then we need to look on a case-by-case basis at what processes should be substituted for the above ideal models.

Having laid out, even if only briefly, this framework for the withholding of poten­tially life-preserving care to patients whose condition is life-threatening, I want now to turn to the case before us.

ARGUMENTS FOR AND AGAINST CONTINUING RESUSCITATION


Should the care be provided? Or does this care fall under one of the above-mentioned types of cases in which potentially life-preserving interventions might be withheld? Type 4 reasons for withholding care are obviously not relevant here, since the facts of the case rule out the very possibility of the patient's requesting that he not receive care, and there is no mention of his family's making such a request.

There are throughout the description of the case references to the costs in time, blood products, and economic charges for the provision of care. But no argument of type 3B — that providing him with care will prevent the provision of care to others who can benefit more — is available on the basis of the facts presented to us.

Perhaps one could mount an argument of type ЗА — that the benefits to the patient are not worth the costs to society — but the brief allusions to costs, even if repeated twice, can hardly serve as the basis for a serious argument of that type. In any case, the weightiest argument for not attempting further resuscitation are arguments of types 1 and 2, so let us turn to them.


Are further resuscitative efforts futile? Two reasons are given for considering further care as futile. It is the experience of this care setting that less than 1% of their patients with blunt trauma who have no vital signs at the scene survive even with full aggressive care (presumably, these statistics are for patients who receive full aggressive care; if they also covered patients for whom care was withheld, the statistics would not be relevant). Second, the patient has had no vital signs for at least ten minutes, and that in itself is the basis for a dim prognosis. Are these reasons sufficient to call the provision of further care futile?

My own immediate reaction and, I believe, the immediate reaction of most people would be to say that the care is futile. But suppose the following argument was offered: we are dealing here with a 25-year-old in good health until now whose only chance of surviving is full aggressive resuscitative efforts. The chance of survival is admittedly dim, but this care is his only chance. So maybe it isn't futile. It is helpful, in thinking about this argument, to go back to our earlier remarks about what is the ideal process of decision making even in type 1 cases.

We claimed there that ideally one should seek the concurrence of the family that the dimness of the chances are so dim that further care is futile. But no family seems to be present in this case, and even if they were, there is just no time to explain enough to them and to give them the ability to come to grips with this sudden crisis so that they can in a rational and thoughtful fashion conclude that further care is futile. What then shall we do about judgments of futility in such emergency cases?


Suppose the following compromise is put forward. Why don't we at this time provide full resuscitative efforts? If they fail, little has been lost. Even if they succeed, the patient's prognosis for surviving the hospitalization is still dim, and if it remains dim, the physicians and the family at a later stage and in a more thoughtful and calm fashion can decide that current care should be discontinued.

This looks like the best compromise on the issue of futility. It also has a major policy advantage. We are probably better off if providers of emergency care attend to doing the best they can to pull patients through immediate crises rather than trying to decide — short of the actual death of the patient — whether further care is futile. Such decisions require a thoughtfulness that may not be compatible with the pressures of an emergency center facing the crisis of a major trauma victim.

There is, of course, another argument suggested by the facts of the case for not providing further care. It is that even if the patient survives, the quality of his life — due to the damages caused by anoxia — will probably be minimal. So isn't this a case where the care is pointless? Again, my own immediate reaction and, I believe, the immediate reaction of most people would be to say that the care is pointless.


But suppose our difficult challenger puts his point again: there is admittedly a small chance of meaningful survival, even smaller than the small chance of survival, but it is his only chance, and he's only 25. Again, if the family was present and could meaningfully participate in the decision that the care is pointless, we could easily accept that decision. But they are not present, and even if they were, with the time we have available, they could not meaningfully participate.

Perhaps we would do better to pull him through now, if we can, and assess (with the aid of his family) pointlessness as well as futility at a time when that can be done in a more thoughtful and calm fashion. Isn't that what is in his best interest? And isn't that the best policy for emergency centers anyway?

WITHHOLDING VERSUS WITHDRAWING TREATMENT


There is one major presupposition of our suggested compromise that needs to be made explicit and discussed. We are proposing that even if the patient is successfully resuscitated, and even if he is stabilized through surgery and intensive supportive care, we might at a later stage on the grounds of futility and / or pointlessness withdraw that supportive care, and certainly not initiate further supportive and therapeutic care, with the concurrence of the patient's family.

Some would object to withdrawing the care already provided, claiming that doing so — with the result that the patient dies — would be murdering the patient. Our belief in the sanctity of life prohibits such a decision, they would say. I think that such a view would be mistaken. To kill a patient is to cause his death. The withdrawing of futile and / or pointless care is not causing the patient's death but is merely allowing his injuries to take their course.


There is, moreover, a certain irony about what is being claimed by our opponents. In the name of the sanctity of life, they force us to choose between not giving the patient his only chance or continuing care even after everyone (including the family) concludes (in the thoughtful fashion that more time allows) that such care is futile and / or pointless. Both on grounds of morality and of policy, we do better to give the patient his chance when there isn't the time to assess these issues with a proper process and to make appropriate choices, including the choice of withdrawing care, when the time is available.

My point then should be clear. Once we adopt the proper moral stance, which is to recognize that we can later withdraw on grounds of futility and / or pointlessness care we have commenced, we are in a position to adopt as a policy that resuscitative efforts in an emergency department setting should continue as long as the patient is alive. Moreover, returning once more to the question of costs, such a policy does not carry with it the horrible cost implications of continuing care indefinitely in such cases.

AGE IS NO FACTOR


I would like to add a remark about one fact in the case whose emotional appeal may be great but whose moral relevance deserves further analysis. The heart of the argument for the compromise is that it is the patient's only chance, and we can withdraw the care later if things continue to look dim. But in putting the argument, I alluded to the patient's age; he is only 25, and there is something terribly tragic about death at such an age. What if he were 75?


That, no doubt, has some implications for his already- dim prognosis. But putting that aside — it isn't enough to make a difference — should we treat that case differently? I think not. That he has lived a full life may make the judgment of futility and pointlessness psychologically easier to make when it is made in a more relaxed and thoughtful fashion, but surely it is not morally relevant to our decision now or then.

CONCLUSIONS


My argument in this case comment is not a general defense of the technological imperative, of doing whatever can be done as long as the patient is alive. Neither is it meant as a general defense of an extreme sanctity of life approach, of preserving life at any cost no matter how futile and pointless it seems. It is, instead, an argument that the emergency department is a good place for doing whatever one can as long as the patient is alive. In part, policy considerations suggest that emergency departments do not provide the time or setting for thoughtful decisions of this sort by providers.


In part, moral considerations suggest that decisions of futility and pointlessness need family concurrence, and emergency departments do not allow for that in a meaningful fashion. And in any case, a proper moral analysis reminds us that we will later have ample opportunities to make, in a more appropriate fashion, the necessary decisions about futility and pointlessness.

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