Clinical ethics Clinical ethics report on the resuscitation of a patient J Med Ethics: first published as 10.1136/medethics-2019-105945 on 6 April 2020. Downloaded from in the emergency department with an uncertain resuscitation status and an implantable cardiac defibrillator Gregory Neal- Smith ,1 Adam Crellin,2 Rebekah Caseley1 1A&E, Oxford University SUMMARY ablation due to worsening heart failure symptoms Hospitals, Oxford, UK Cardiopulmonary resuscitation of a patient with an and recurrent episodes of slow VT. 2Medical Sciences Division, Oxford University Medical uncertain resuscitation status, and a discharging He lived with his wife at home and was fully School, Oxford, UK implantable cardiac defibrillator, presents a significant independent. There was no available documenta- ethical challenge to healthcare professionals in the tion of the patient’s resuscitation status, and as the Correspondence to emergency department. Presently, no literature patient appeared well this was not discussed during Mr Gregory Neal- Smith, John discusses these challenges or their implications for his initial assessment. Radcliffe Hospital, Oxford OX3 ethical healthcare delivery. This report will discuss the 9DU, UK; The patient attended the ED as he had felt dizzy gregnealsmith@ doctors. org. uk issues that arose during the management of such a and fallen over, hitting his head on the bathroom case and attempt to raise awareness among healthcare sink. He had amnesia of the event and there was a Received 18 November 2019 professionals to ensure better preparation for similar presumed loss of consciousness. During the same Revised 11 March 2020 situations. Accepted 20 March 2020 day the patient had multiple episodes of presyn- Published Online First cope, during which he noted that he could not 6 April 2020 feel his radial pulse. He sent an interrogation of INTRODUCTION his ICD to the technicians which was reported as An- 82- year old man with an implantable cardiac normal. defibrillator (ICD) was brought to the emergency In the ED, his examination was unremarkable department (ED) following an episode of syncope. and his observations were stable. His ECG showed He subsequently had a cardiac arrest, and as no a paced rhythm with a heart rate of 63. His blood DNACPR (“Do not attempt cardiopulmonary and a CT head (completed in accordance with resuscitation”) decision was documented resuscita- NICE guidelines on head injury) were normal. tion efforts were started. The difficulty caring for The patient was diagnosed with likely cardiac the patient was threefold: an unclear DNACPR syncope and was admitted under the medical team status, a rapidly fluctuating clinical condition due for interrogation of his ICD in the morning. An http://jme.bmj.com/ to a discharging ICD and a lack of consultant pres- hour later, the patient collapsed while changing ence resulting in an ethically challenging resuscita- for bed. The patient lost consciousness and had tion scenario. no palpable central pulse, and his monitor showed Clear documentation of DNACPR decisions is ventricular fibrillation (VF). A resus call was put extremely important and it should be easily acces- sible to avoid confusion during an emergency. As a out, cardiopulmonary resuscitation was started and result of this case, we would advocate a patient’s his ICD delivered several shocks in an attempt to DNACPR status is displayed on electronic patient cardiovert his VF. on October 1, 2021 by guest. Protected copyright. records, if used within Trusts. Furthermore, imme- The patient alternated between VT, VF and sinus diate completion of DNACPR forms should occur rhythm. During this treatment, his wife stated that whenever patients express this wish, regardless of at his last cardiology clinic appointment he had location, including specialty clinics. We would also informed his cardiologist that he did not want to stress the importance of pre-emptive discussions be resuscitated. He had also handed in a letter with patients and family, and consultant availability. detailing this. The cardiologist had not signed a DNACPR form, so his decision had not been formalised. THE CASE As the patient had a witnessed cardiac arrest, he An 82- year- old man was brought to the ED was in a shockable rhythm and there was no formal DNACPR, some members of the team were uncom- © Author(s) (or their by ambulance in the evening with his wife and employer(s)) 2020. No daughter, following an episode of syncope. fortable about whether CPR should be stopped. commercial re-use . See rights He had a background of an ICD inserted 18 Following a discussion with the team and family, and permissions. Published months earlier and subsequent cardiac resynchroni- it was felt that the patient was unlikely to recover by BMJ. sation therapy, atrial fibrillation, recurrent ventric- due to his refractory VF and poor cardiac function. To cite: Neal- Smith G, ular tachycardia (VT), coronary artery bypass In view of the patient's previously expressed wishes Crellin A, Caseley R. graft, severe left ventricular systolic impairment, regarding resuscitation, the decision was made to J Med Ethics deactivate his ICD. Shortly after this, the patient 2020;46:581–583. hypertension and chronic kidney disease. He was admitted under cardiology the previous month for sadly died. Neal- Smith G, et al. J Med Ethics 2020;46:581–583. doi:10.1136/medethics-2019-105945 581 Clinical ethics ETHICAL REVIEW investigating differences in ethical decision- making between J Med Ethics: first published as 10.1136/medethics-2019-105945 on 6 April 2020. Downloaded from The implementation of cardiovascular implanted electronic consultants and non- consultant doctors in the ED appear to be devices, including ICDs, has dramatically increased in recent non- existent at the time of writing. Also, studies investigating years due an ageing population and an increased number of indi- differences in patient outcomes in the ED between consultants cations for use.1 At present, extensive literature exists discussing and non- consultant doctors in the UK are few. However, a the deactivation of ICDs during end- of- life care and the resus- 5- year retrospective study of patient survival following trauma, citation of patients with an uncertain resuscitation status. compared with predicted survival according to the Trauma However, to our knowledge, no literature currently discusses Score- Injury Severity Score, showed that patients treated by the legal and ethical challenges of resuscitating a patient with an consultants had significantly better survival than those treated by 5 uncertain resuscitation status and an active ICD in situ. There- non- consultant grade doctors. A study analysing the impact of fore, this case report will discuss the issues which arose during senior review of initial assessments made by junior doctors in the the management of such a case, to broaden the discussion so ED reported that senior doctors changed the primary outcome 6 those facing similar challenges may be better prepared. plan in 28% of cases. The difficulty caring for our patient involved ethical and logis- Overall, numerous reviews conclude that a delay in consultant tical issues over three areas. First, his resuscitation status was involvement in patient care increases mortality and morbidity 7 8 unclear due to the lack of documentation; second, the patient in a range of fields, including emergency medicine. This is had a complex resuscitation which prevented the team from thought in part to be due to a consultant’s experience which focusing on the ethical issue of continuing CPR and third, the enables them to acknowledge the unusual, unexpected and unfamiliar which in the emergency medical setting can lead to duty ED consultant was not present to assist in the decision. 8 With regards to his resuscitation status, the law supplies clear dramatic differences in outcome. The Royal College of Emer- guidance to ensure appropriate action can be taken. Common gency Medicine recognises this in both their 2010 and 2018 emergency medicine consultants’ workforce recommendations, law states that a person with capacity can refuse treatment, 9 10 including CPR, but that a person may not demand treatment particularly in leading the resuscitation of critically ill patients. that a doctor does not consider to be in their best interests.2 If However, a 2012 national audit of patients undergoing CPR as a result of an in-hospital cardiorespiratory arrest demonstrates the person lacks capacity, such as in this case when the patient 11 3 a very low level of consultant involvement. They found that arrested, then the Mental Capacity Act 2005 applies. It states only 9% of cardiac arrest calls were led by a consultant and only that decisions should be made in the patient’s best interests, 40% of acute admissions were identified to have been seen by a taking into account his or her wishes before capacity was lost and consultant within 12 hours.11 These studies are however diffi- those of the people close to the patient.3 The Mental Capacity cult to generalise to the whole of the UK. Regarding our case, Act 2005 also encompasses a patient’s right to advance refusal extrapolation of the above conclusions in the absence of specific of treatment, including CPR, should they lose capacity.3 The evidence regarding ethical decision- making between consultants final piece of legislation was established in the case of Airedale and non- consultant doctors in the ED indicates a trend towards NHS Trust vs Bland. It clarified that withholding or withdrawing better decision making when a consultant leads care. life- sustaining treatment may be appropriate if it is not in the While attempts to resuscitate our patient were rapidly deemed patient’s best interest.4 futile and thus a consultant’s presence would likely have made Considering the three pieces of legislation in the context of little difference to their outcome, the evidence suggests that http://jme.bmj.com/ our case, it is our duty to provide care in the best interests of the the experience of a consultant improves the speed of decision- patient as no formal documentation of resuscitation status was making.