Dear Sir

Patients or families may ask for care that is highly unlikely to improve health outcomes. Healthcare providers, however, are not obliged to provide such care when there is scientific and social consensus that the treatment is ineffective. If the purpose

of a medical treatment cannot be achieved, the treatment can be considered futile.

Terminating Cardiac Arrest Resuscitative Efforts in Adult In Hospital Cardiac Arrest (IHCA):

In the hospital the decision to terminate resuscitative efforts rests with the treating physician and is based on consideration of many factors, including witnessed versus unwitnessed arrest, time to CPR, initial arrest rhythm, time to defibrillation, comorbid disease, pre-arrest state, and whether there is ROSC at some point during the resuscitative efforts. Clinical decision rules for in-hospital termination of resuscitation may be helpful in reducing variability in decision making57; however, the evidence for their reliability is limited, and rules should be prospectively validated before adoption.

***2010 American Heart Association Guidelines for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care (Part 3: Ethics)

Thank you very much Alireza Baratloo. Yes, there are technical, clinical and scientific basis to take the decision. My dilemma roots to the ethical principle of 'respect to autonomy'. How should we respect the autonomy of the patient (patient party) while deciding the futility of treatment?

To perform CPR or not, and when to stop, who decide to stop the procedure and when to discuss futility??

The main questions for ICU’s and ED physicians.

Whereas, it is relatively easy in the ICUs to discuss these questions, since patients are classified, de facto, with “full code ICU management, three to five days unlimited ICU management before reappraisal and potential end of life decision, do not increase invasive procedures or vasopressor administration, NTBR, and withdrawal”. Despite, these recommendations, in May 2010, “1 in 4 ICU nurses and 1 in 3 ICU physicians believed that they delivered inappropriate care to at least 1 of their patients on the day of the survey “, (Piers RD, Azoulay E, Ricou B, et al. Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. JAMA. 2011; 306(24):2694-2703.)

In the ED, we may have three possibilities.

First, the patient is not yet in cardiac arrest (CA) and ED team have the possibility to discuss with the family and thus decide, in view the previous health status and the “ the desiderata of the patient”, to perform or not CPR, if requested.

Second, CPR is performed in absence of a family member and without informations concerning the previous health status, resuscitation should be performed as usual, until…. If the patient survives, as for all patients who suffered from CA, the outcome will be frequently clear crystal within the first three ICU days.

Third, whereas CPR is being performed, a discussion with a family member or a relative is possible. ED and ICU’s physicians will explain the CA possible consequences and propose to withdraw or not life support, according to CA story (unwitnessed, delay before CPR initiation, responsiveness ..) and of course pre- arrest conditions.

For the patients admitted in wards, medical teams frequently anticipate whereas ICU admission is warranted or not, particularly for cancer patients, and thus, de facto, the futility of CPR for patients which should not be transferred to the ICU. Patient preferences for resuscitation and end-of-life issues, are of interest but very rare…

At evidence, information given by ICU’s or ED physicians to patients’ relatives for a “shared decision-making”, looks like “together decision”, but in clinical practice, medical decision seems to be the major factor. In case of conflict with the family, CPR followed by ICU admission until conflict resolution, and/or situation appraisal within the first ICU days, should be proposed.