Ethical Issues of Resuscitation

Revised January 2021, June 2015

Originally approved June 2008 combining "Ethical Issues of Resuscitation" (2001) and "Do Not Attempt Resuscitation (DNAR) in the Out-of-Hospital Setting" (2003)

The American College of Emergency Physicians supports the following principles.

• Patients who may benefit from resuscitation efforts should have equitable access to such efforts.
• Decisions to attempt resuscitation must take into account the accepted standards of medical care, the safety of the medical personnel, and known patient preferences.

It is appropriate for out-of-hospital providers to honor valid orders to limit life- sustaining interventions at the end of life. Standardized guidelines and protocols should exist in all EMS systems to direct out-of-hospital personnel’s resuscitative efforts. Educational information regarding such policies should be disseminated to the community and to out-of-hospital and hospital providers.

Patient goals and preferences for end of life care should be honored by out-of- hospital and hospital providers at the end of life. EMS out-of-hospital order systems should support efforts to provide or forgo these treatments based on available information.

The appropriate surrogate decision-maker, as defined by state law, should be involved in decisions regarding life-sustaining treatments if immediately available. Additional sources of information to guide treatment decisions may come from patient advance directives, family, or primary physicians as time permits. EMS systems should honor state-recognized orders addressing life- sustaining treatments.

If the patient’s goals or medical circumstances are unclear, medically appropriate resuscitative measures should be undertaken. It is ethically permissible for treatments, once started, to be withdrawn when additional information becomes available. This information may include the lack of response to treatment or definitive information about the patient’s goals for life-sustaining treatments.

Resuscitative efforts may be appropriately not initiated, and non-beneficial treatment may be withdrawn or limited in circumstances such as the lack of immediately available resuscitation resources, or when there is no realistic likelihood of benefit to the patient based on existing scientific evidence and reasonable medical judgment.

Resuscitative efforts may also be appropriately not initiated, withdrawn, or limited in unsafe situations, such as during a global pandemic, a violent situation, or an environmental disaster, in order to protect staff properly. Facilities should develop protocols to guide alteration of resuscitation practices in these extraordinary circumstances.

When resuscitative efforts are not indicated, emergency physicians should assure appropriate medical and psychosocial care during the dying process.