• Aucun résultat trouvé

ethics of 11. resuscitation The and end-of-life decisions European Council Resuscitation Guidelines for Resuscitation 2015Section Resuscitation

N/A
N/A
Protected

Academic year: 2021

Partager "ethics of 11. resuscitation The and end-of-life decisions European Council Resuscitation Guidelines for Resuscitation 2015Section Resuscitation"

Copied!
10
0
0

Texte intégral

(1)

ContentslistsavailableatScienceDirect

Resuscitation

j o ur na l h o me p a g e:ww w . e l s e v i er . c o m / l o c a t e / r e s u s c i t a t i o n

European

Resuscitation

Council

Guidelines

for

Resuscitation

2015

Section

11.

The

ethics

of

resuscitation

and

end-of-life

decisions

Leo

L.

Bossaert

a,∗

,

Gavin

D.

Perkins

b,c

,

Helen

Askitopoulou

d,e

,

Violetta

I.

Raffay

f

,

Robert

Greif

g

,

Kirstie

L.

Haywood

h

,

Spyros

D.

Mentzelopoulos

i

,

Jerry

P.

Nolan

j

,

Patrick

Van

de

Voorde

k,l

,

Theodoros

T.

Xanthos

m,n

,

on

behalf

of

The

ethics

of

resuscitation

and

end-of-life

decisions

section

Collaborators

1 aUniversityofAntwerp,Antwerp,Belgium

bWarwickMedicalSchool,UniversityofWarwick,Coventry,UK

cCriticalCareUnit,HeartofEnglandNHSFoundationTrust,Birmingham,UK dMedicalSchool,UniversityofCrete,Heraklion,Greece

eEthicsCommitteeoftheEuropeanSocietyforEmergencyMedicine(EuSEM),UK fMunicipalInstituteforEmergencyMedicineNoviSad,NoviSad,Serbia gUniversityHospitalBernandUniversityofBern,Bern,Switzerland

hRoyalCollegeofNursingResearchInstitute,WarwickMedicalSchool,UniversityofWarwick,Coventry,UK iUniversityofAthensMedicalSchool,Athens,Greece

jDepartmentofAnaesthesiaandIntensiveCareMedicine,RoyalUnitedHospital,andUniversityofBristol,Bath,UK kUniversityHospitalandUniversityGhent,Belgium

lFederalDepartmentHealth,Belgium mUniversityofAthens,MedicalSchool,Greece nMidwesternUniversity,Chicago,USA

SummaryofchangessincetheERC2010guidelines

The traditional medical-centred approach with an emphasis onbeneficence has shiftedtowards a balanced patient-centred approachwithgreateremphasis onpatientautonomy.Thishas resultedinareadinessforunderstandingandinteractionbetween patientandhealthcareprofessionals.Futureguidelinesmay ben-efitfrominvolvementofallstakeholders:membersofthepublic, patients,survivorsandthesocietyasactivepartnersin understand-ingandimplementingtheethicalprinciples.

Thecontentandimplementationofthetraditionalethical prin-ciplesareplacedinthecontextofapatient-centredapproachto resuscitation:

• Autonomy,includingrespectforpersonalpreferencesexpressed in advance directives,which implies correct information and communication.

• Beneficence,including prognostication,when tostart, futility, ongoingCPRduringtransportation,specialsituations,withclear distinctionbetweensuddencardiacarrestandexpectedcessation ofcardiacfunctionandrespirationinterminalsituations.

∗ Correspondingauthor.

E-mailaddresses:leo.bossaert@erc.edu,leo.bossaert@gmail.com(L.L.Bossaert).

1 ThemembersofTheethicsofresuscitationandend-of-lifedecisionssection

CollaboratorsarelistedintheCollaboratorssection.

• Non-maleficence, including DNAR/DNACPR, when to stop/ withholdandinvolvementofpatientorproxy.

• Justiceandequalaccess,includingavoidinginequalities. Whilstthesadrealityisthatthemajorityofthosethatsustain acardiacarrestdonotsurvive,recentstudiesprovideevidenceof steadyimprovementinoutcomesparticularlywheretheformula ofsurvivaliswellimplemented.Specificcasesofrefractory car-diacarrest,whichwouldhistoricallyhavebeenfatal,maybenefit fromadditionalinterventionalapproaches.Afurtherimprovement insurvivalmaybeexpectedbyapplyingclearguidanceforstarting, notstarting,withdrawingorwithholdingresuscitationattempts, andbyidentifyingrefractorycasesthatmayrespondtoadvanced interventions.

Europe is a patchwork of 47 countries (Council of Europe) withdifferencesinnationallaws,jurisdiction,culture,religion,and economiccapabilities.Europeancountriesinterprettheethical rec-ommendationsofresuscitationinthecontextofthesefactors.

AsurveyofcurrentethicalpracticeacrossEuropewasconducted inthecontextoftheseguidelines.Asignificantvariabilityinthe approachtocardiopulmonaryresuscitation(CPR)andend-of-life was documented. Whilst areas for improvement were identi-fied,ithighlightedatrend towardsbetterapplicationof ethical principles.

Theneedforharmonisationinlegislation,jurisdiction, terminol-ogyandpracticeremains.ThemissionoftheERCanditsGuidelines istocontributetothisharmonisation.

http://dx.doi.org/10.1016/j.resuscitation.2015.07.033

(2)

NewEuropeanUnion(EU)regulationpermittingdeferred con-sentwillharmoniseandfosterresearchofemergencyinterventions acrossEUMemberStates.

Healthcareprofessionalsareresponsibleformaintainingtheir knowledge,understandingandskills,andtounderstandtheethical principlesbeforebeinginvolvedinarealsituationwhere resusci-tationdecisionsmustbemade.

Introduction

Suddenunexpectedcardiacarrest(CA)isacatastrophic unex-pectedbutpotentiallyreversibleeventthatinvolvesfamily,friends andsociety.InEuropecardiacarrestoccursin0.5–1.0per1000 inhabitants per year. Although a slow improvement has been observedoverrecentyears,survivalafterout-of-hospitalCardiac Arrest(OHCA)remainslowwithanaveragesurvival tohospital dischargeof7.6%.1–9

Potentiallyreversiblesuddenunexpectedcardiacarrestshould bedistinguishedfromtheexpectedcessationofcirculationand res-pirationinaterminalcondition.Bettermedicalknowledge,new and advanced interventions,and increasingexpectations ofthe publichaverenderedethicalconsiderationsanimportantpartof anyend-of-lifeinterventionordecision.Thisincludesoptimising resultsforindividualpatientsandsocietybyappropriateallocation ofresources.

Inrecent yearsthere hasbeena shiftfromadoctor-centred approachwithemphasisonbeneficence,towardsapatient-centred approachwithgreateremphasisonpatientautonomy.Thischange isreflectedinthe2015ERCethicsguidelinesforresuscitationand end-of-lifedecisions.

Thischapterprovidesinformationand guidanceonthe prin-ciplesofethics:ethicalandprofessionalguidanceforhealthcare professionals responsible for providing resuscitation including when tostart and when to stopresuscitationand special con-siderationsrequiredforchildrenandfororgandonationafteran unsuccessfulresuscitationattempt.

Thehealthcareprofessionalshouldunderstandtheethical prin-ciplesbeforebeinginvolvedinarealsituationwhereresuscitation decisionsmustbemade.

WealsoreporttheinitialfindingsfromaEuropeansurveyon EthicalPractices,whichdocumentedsignificantvariationbetween countriesintheapproachtocardiopulmonaryresuscitation(CPR) andend-of-lifepractices.

Thereisaclearneedforharmonisationinlegislation, terminol-ogyandpractice.ThemissionoftheERCGuidelinesistocontribute tothisharmonisation.

Aspectsofethicsforresuscitationandend-of-lifedecisions

Ethicsisdefinedasthewaysofexaminingandunderstanding themorallife,ortheapplicationofethicalreasoningtomedical decisionmaking.Thekeyprinciplesofmedicalethicsare: auton-omyoftheindividual,beneficence,non-maleficenceandjustice. Dignityandhonestyarefrequentlyaddedasessentialelementsof ethics.11–13

Theprincipleofpatientautonomy

Respect for autonomy refers to a physician’s obligation to respectapatient’spreferencesandtomakedecisionsthataccord with a patient’s values and beliefs. Patient-centred healthcare placesthepatientatthecentreofthedecision-makingprocess, rather than as a recipient of a medical decision. This requires patientsto have an adequateunderstanding of relevant issues regarding theirtreatmentoptions, thusenabling them tomake informed decisions or participate in shared decision-making. Patienteducationhascontributedsignificantlytothischangein

emphasis.Theprincipleofautonomyisimplementedthroughfree andinformedconsent,andrecognisesthatthepersonmaychange theirdecisionatanytime.Applyingthisprincipleduringcardiac arrest where the patient is often unable to communicate pre-ferencesischallenging.11,14–16Moreover,thelegallydocumented

wishes of an individual patient may not be readily available, causingfurtherethicaldilemma:howcanhealthcare profession-alsembracepatient-centricitywhentheviewsofthepatientare unknown?11,17–19

Theprincipleofbeneficence

Beneficenceimpliesthatinterventionsmustbenefitthepatient after assessing relevant risk and benefit. Evidence-based clini-calguidelinesexisttoassisthealthcareprofessionalsindeciding whichtreatmentapproaches aremostappropriate.20–22

Increas-ingly, patientsare involved as active partners in the guideline developmentprocess,ensuringthatpatient’sviewsand perspec-tivearecapturedintheguidanceprovided.23Suchinvolvement,

however,hasnotyetbeenwitnessedinthecontextofresuscitation guidelines.

Theprincipleofnon-maleficence

Non-maleficenceor‘primumnonnocere’stemsfromthe Hip-pocraticaxiom‘helporatleastdonoharm’.CPRshouldnotbe performedinfutilecases.However,itisdifficulttodefinefutility in a waythat is precise,prospective andapplies tothe major-ityofcases.CPR isaninvasiveprocedurewitha lowlikelihood ofsuccess.Advancedirectivesarerarelyavailabletoemergency healthcareprofessionals.Therefore,CPRhasbecomethenormfor mostpatientswithacute,life-threateningconditions.24,25

Theprincipleofjusticeandequitableaccess

Justiceimpliesthathealthresourcesaredistributedequallyand fairly,irrespectiveofthepatient’ssocialstatus,intheabsenceof discrimination,withtherightforeach individualtoreceive the currentstandardofcare.Theappropriateallocationofresources hasbecomeanimportantconsiderationforinvasiveprocedures. CPRisaprocedurerequiringcoordinatedeffortsofmanyhealthcare professionals.TheethicalconsiderationsregardingCPRand end-of-lifedecisionsincludeachievingthebestresultsfortheindividual patient,forrelativesandforsocietyasawholebyappropriate allo-cationof availableresources.Thereisnoconsensusaboutwhat constitutesajustandfairmethodofbalancingthepreferencesand requirementsofindividualpatientsagainstthediverseneedsof society.11,13,19,21,26

Withholdingspecificmedicalcaredue tofinancialmotivesis notacceptablebutitmaybeappropriatetoconsidertheoverall costsandpotentialbenefitstotheindividualpatient,thefamily andsociety.13,21,27–29

Thereisevidencethatcitizensfromlowersocioeconomicgroups havebothanincreasedincidenceandlowerchanceofsurvivalof OHCA.Thelikelihood ofa personreceivingbystanderCPR after a cardiac arrest is nearly five times greater in higher income neighbourhoods compared withlower income ones. Caucasian patientsaremorelikelytoreceivebystanderCPRthanotherethnic groups.2,30–39

Medicalfutility

TheWorldMedicalAssociation(WMA)definesfutilemedical treatmentasatreatmentthat“offersnoreasonablehopeof recov-eryorimprovement”orfromwhich“thepatientispermanently unabletoexperienceanybenefit”.Resuscitationisconsideredfutile when the chances of good quality survival are minimal.40 The

firstprerequisitetoconsideratreatmentfutileisthepresenceor absenceofamedicalindication.Thedecisionnottoattempt resus-citationdoesnotrequiretheconsentofpatientsorofthoseclose

(3)

tothem,whooftenhaveunrealisticexpectationsaboutthelikely successandpotentialbenefitsofresuscitation.41,42Startingafutile

treatmentmayofferfalsehopetothefamilyandpatientthatmay underminethepatient’sabilityforrationaljudgmentand

auton-omy.40,43However,decisionmakershaveadutytoconsultthe

patientorarepresentativeifthepatientlackscapacity,in accor-dancewitha“clearandaccessiblepolicy”.44–46Themedicalteam

mustexplainthatthedecisionnottoattemptresuscitationdoesnot meangivinguporthatthepatientwillbeignoredorabandoned, butratherthattheintentistoprotectthepatientfromharmand tomaximisecomfortandqualityoflife.44,47

Somecountriesallowprospectivedecisionstowithhold CPR whilst in others countries or religions withholding CPR is not allowedorconsideredillegal.Thereisalackofconsistencyinterms suchas‘DoNotAttemptResuscitation’(DNAR),‘DoNotAttempt CardiopulmonaryResuscitation’(DNACPR)or‘AllowNaturalDeath’ (AND).Thisconfusinguseofacronymsmaygenerate misunder-standingsinnationallegislationandjurisdiction48,49

Advancedirectives

Advance directives are decisions about treatment provided prospectivelybyanindividualincasetheyareunabletoparticipate directlyinmedicaldecision-makingatsomepointinthefuture.50

Advancedirectivescantaketwodifferentbutnotmutually exclu-siveforms:(1)‘LivingWills’arewrittendocumentsthatexpress aperson’spreferencesregardingtheprovisionorthewithholding ofspecifiedtreatmentsintheeventthattheybecomeunableto makedecisionsinthefuture;and (2)a‘Lastingpowerof attor-neyforhealthcare’allowsindividualstoappointaproxy(e.g.,a trustedrelativeorfriend)whocanmakehealthcaredecisionson theirbehalfincasetheylosedecision-makingcapacity.51

The advance directives must meet three criteria: existence, validity and applicability. Physicians must not delay resuscita-tioninterventionswhiletryingtoestablishifanadvancedirective prohibitingCPRexists.51NeithermustCPRbeattemptedifitis

con-sideredmoreharmfulthanhelpful,evenifcontrarytoavalidand applicableadvancedecision.

In severalcountries advance directives have the same legal forceascontemporaneousdecisions.However,theirapplicability iscomplicatedbythechallengeofdraftingadirectivethat accu-ratelyrepresentsapatient’swishesatthetimeofwriting.52Indeed,

peopleoften adapt todisabilities, and preferences maychange overtime.Therefore,periodicreviewsofdirectivesarerequiredto ensurepatients’currentwishesandcircumstancesareaccurately reflected.41,52,53

Article9oftheConventiononHumanRightsandBiomedicine requiresphysicians to“takeintoaccount” previouslyexpressed wishesoftheirpatients.19 However,thelegalstatus ofadvance

directivesinthenationallegislationofEuropeancountriesisvery disparate.Severalcountrieshaveadoptedspecificlawsassigning bindingforceto advancedirectives aboutend of life decisions, includingresuscitation.51

HumanRightsrelevanttoresuscitationandend-of-lifedecisions Policiesaboutresuscitationandindividualdecisionsof health-care professionals must comply with humanrights. Provisions relevanttodecisionsaboutattemptingCPRincludethefollowing rights:tolife;toprotectionfrominhumanordegradingtreatment; torespectforprivacyand familylife;tofreedomofexpression, whichincludestherighttoholdopinionsandtoreceive informa-tion;andtobefreefromdiscriminatorypracticeinrespectofthese rights.19FailingtoinvolveapatientatthetimeofwritingaDNAR

orderbreachesArticle8of theEuropeanConventionof Human Rights.45

Patient-centredcare

The increasing centricity of the patient within healthcare demands that we seek to understand the perspective of the survivor ofcardiacarrest, withassessment seekingtobe inclu-sive of clinical and patient-reported outcomes over the short and longer-term. This hasbeen recognised withinthe updated UtsteinResuscitation Registrytemplate for out-of-hospital car-diacarrest,whichrecommendstheassessmentofpatient-reported outcomesandthequalityoflifeofsurvivors.54However,specific

assessmentguidancedoesnotcurrentlyexist. TheCOSCA(Core OutcomeSet—CardiacArrest)initiativewillseekinternational con-sensus on what should be measured and when in all clinical trialsofcardiacarrest,andmakerecommendationsonboth clin-icalandpatient-reportedoutcomes.55,56Suchguidancemayalso

inform patient-centredoutcome assessment in routinepractice andregistries,informingmoretargetedtreatmentandallocation ofresourcesforsurvivorsofcardiacarrest.54–58

Ethically,wecannotignorethepatientperspective.However, ensuringthatpatient-centredoutcomesarecapturedtothebest effectrequiresanimprovedunderstandingofwhatmatters, for whom,inwhatcontextandwhen:thisrequiresafurther commit-menttoworktogetherwiththepublic,withthesurvivorsofcardiac arrestandtheirfamiliesaspartnersinthisprocess.59

Practicalimplicationsforin-andout-of-hospitalcardiac

arrest

Outcomefromsuddencardiacarrest

Resuscitationattemptsareunsuccessfulin70–98%ofcases.In pre-hospitalsystemswithawell-organisedimplementationofthe elementsofthe‘formulaofsurvival’20about1/3–1/2ofpatients

mayachievereturnofspontaneouscirculation(ROSC)withCPR, withasmallerproportionsurvivingtothehospitalcriticalcareunit. Smallerproportionsstillsurvivetohospitaldischargewithgood neurologicaloutcome.8

Thebestresuscitationoutcomeisforanindividualtobe cogni-tivelyunimpairedandwithanacceptablequalityoflife,ortoreport nosignificant deterioration when compared tothe pre-morbid state.

However,studieshavereportedcognitiveimpairmentinupto 50%ofsurvivors.9,60,61Moreover,whereacceptablelevelsof

qual-ityoflifehavebeenreported,thishasbeenassessedusinggeneric, preference-basedutilitymeasuressuchastheEuroQoLEQ-5Dor Health UtilityIndex, or generichealth status measuressuchas theShortForm12-itemHealthSurvey(SF-12).57,62,63Whilst

pro-vidingabroadoverviewofhealthstatusandausefulcomparator withthegeneralpopulation,genericmeasurescannotcapturethe complexitiesofspecificconditionsanditisunclearifthey accu-ratelyassesstheoutcomesthatreallymattertotheCAsurvivors.55

Consequently,theymayunderestimatethehealthneedsand expe-riencesofsurvivors, andareoften lessresponsivetoimportant changesinrecoverythanwell-developedconditionordomain spe-cificmeasures.55

EarlyadequateCPRmayincreasesurvivalbeyond50%.64,65

Sub-stantialvariationinsurvival isseen betweencommunities.66–69

Realimprovementsinglobaloutcomewillrequirea community-centred‘publichealth’approach.8,70 Policy-levelexecutivesneed

tobecomeawareoftheircrucialroleinthis. In-hospitalcardiacarrest(IHCA)

Followingin-hospitalcardiacarrest,thedefaultpositionisto startresuscitationunlessadecisionwasmadetowithholdCPR.

(4)

Decisionstowithholdresuscitationareusuallytakenbyasenior physicianincollaborationwithmembersofthemulti-professional team.71Resuscitationdecisionsshouldbereviewedfollowingan

emergencyadmissiontohospital,afteranyimportantchangesin patientstatus /prognosis,following a requestfromthepatient or their relatives, and prior to discharge / transfer to another facility.72Standardisedsystemstowithholdresuscitationdecrease

theincidenceoffutileresuscitationattempts.72Instructionsshould

bespecific,detailed,andtransferableacrosshealthcaresettings, andeasilyunderstood.73,74Theremaybeoccasionswherea

clini-ciandecidesitisnecessarytooverrideapriordecisiontowithhold CPR.Suchcircumstancesmightincludeasuddenarrestduetoa readilyreversiblecause(e.g.,choking,blockedtracheal tube)or whereapatientisundergoingaspecificprocedureorgeneral anaes-thesia.Wheneverpossiblesuchcircumstancesshouldbediscussed inadvancewiththepatienttoestablishtheirpriorwishes.

DeterminingwhenCPRislikelytobeunsuccessfulor,inother words,futile, is oftendifficult.Two clinicaldecision rules have beendeveloped usingdata from theAHA Getwith the Guide-lines Programme (n>50,000 cases).The first developed a flow chartindicatingthelikelihoodofsurvivaltodischargewithgood neurological function. In this model, admission froma nursing facilitywitha cerebralperformancecategory (CPC)of 2or less hada verylow (2.3%)chanceofsurvival aftercardiacarrest,as didadmissionfromhomeoranotherhospitalandaCPCscoreof 3(2.2%survival).75 Otherimportantpredictorsofpooroutcome

wereadvancingage,presence of organfailure, malignancy and hypotension.Absenceofco-morbidities,presenceofarrhythmias andmyocardialinfarctionwereassociatedwithbetteroutcomes. TheGo-FARscore,producedbythesamegroupuses13pre-arrest variablestopredictoutcome.75Alowscorepredictedgood

out-come(27%favourablesurvival)whilstahighscorepredictedpoor outcome(0.8%favourablesurvival).Goodneurologicalfunctionat admissionpredictedgoodoutcomewhilstmajortrauma,stroke, malignancy,sepsis,non-cardiacmedicaladmission,organfailure andadvancingagewerekeydeterminantsofadverseoutcomes. Predictionstudiesare particularlydependentonsystemfactors suchastimetostartofCPRandtimetodefibrillation.These inter-valsmaybeprolongedinthetotalstudycohortbutmaynotbe applicabletoanindividualcase.

Inevitably,judgementswillhavetobemadebasedonall avail-ableinformation.Decisionsshouldnotbemadebasedonasingle element,suchasage.76Therewillremaingreyareaswhere

judge-mentisrequiredforindividualpatients.

It is difficultto definean optimalduration for resuscitation attempts.InafurtherstudyfromtheAHAGetWithThe Guidelines-Resuscitation(GWTG-R) registry,88% of patientswhoachieved sustainedROSCdidsowithin 30min.77 Asa rule,resuscitation

shouldbecontinuedaslongasVFpersists.Asystoleformorethan 20min duringALS in theabsenceof a reversible causeis gen-erallyacceptedasanindicationtoabandonfurtherresuscitation attempts.However,therearereportsofexceptionalcasesthatdo notsupportthegeneralrule,andeachcasemustbeassessed indi-vidually.

Presently,therearenovalidprognosticationtoolsofpoor out-comeduringthefirstfewhoursafterROSC.Thepredictionoffinal neurological outcome in CA patients remaining comatoseafter ROSCisgenerallyunreliableduringthefirst3daysafterCAand untilthefirst2–3daysafterterminationofhypothermia.

Reliableprognosticationofapooroutcomeincomatosecardiac arrestsurvivorssupportsdiscussionswithrelativesanddecisions towithdrawlife-sustainingtherapy.Guidelinesforprognostication insuchpatientsaredescribedindetailinthepostresuscitationcare chapterofthe2015ERCGuidelines.27

Weshouldbearinmindthattheimplementationofa termina-tionofresuscitation(ToR)protocolwillinevitablyintroducesome

self-fulfillingprophecyandmustbechallengedperiodicallyasnew treatmentsevolve.

Thefocusofmostpublishedstudieshasbeenonpredictingpoor outcomesamongst comatosesurvivors of cardiacarrest. Future researchshouldalsoconsiderfactorsthatwouldpredictagood outcomeinordertoinformtreatmentdecisionsanddiscussions withrelatives.

Out-of-hospitalcardiacarrest(OHCA)

ThedecisiontostartordiscontinueCPRisusuallymore chal-lengingoutsideahospital.78,79Specificchallengesincludethelack

ofsufficient,unequivocalinformationaboutapatient’swishesand values,comorbiditiesandbaselinehealthstatus.Accessto diagnos-ticteststoidentifyreversiblecausesislimitedandteamsingeneral aresmallandinmanycountriesonlycompriseemergency medi-caltechniciansorparamedics.Prognosticassessmentintermsof survivalandsubsequentqualityoflifecarriesahigherriskofbias andthusinjustice.80,81Consideringthisandtheprovencorrelation

betweentimetoBLSorfirstshockandoutcome,thedefaultfor OHCAstillneedstobetostartCPRassoonaspossibleandaddress questionslater.Exceptionsaretheconditionsthatenable recog-nitionoflifeextinct(ROLE),namelymassivecranialandcerebral destruction,decapitation,decompositionorputrefaction, inciner-ation,dependentlividity(hypostasis)withrigormortis,andfoetal maceration. In such cases,the non-physician might be making a diagnosisofdeathbutis notcertifyingdeath, which,in most countries,canbedoneonlybyaphysician.

CPRthathasnochanceofsuccessintermsofsurvivalor accept-ablequalityoflifeispointlessandmayviolatetherightformercy anddignityinthefaceofdeath.Definingthis‘nochanceof suc-cess’ ishoweververy difficultand,incontrasttoothermedical interventions,ithasbeenarguedthatsuccessratesoflessthan 1%stilljustifytheresuscitationeffort.78,81,82Institutional

guide-linesfortheTerminationOfResuscitation(ToR)inthepre-hospital environmentareverymuchneededtoreduceunwantedvariability inthisdecision-making.

Several authors have developed and prospectively tested unequivocalterminationofresuscitation(ToR)rules.One prospec-tivestudy demonstratedthat a basiclife supportToRrule was 100% predictive of death when applied by defibrillation-only emergency medical technicians. Subsequent studies showed external generalisabilityofthis rule,butothers challengedthis. TheimplementationofaToRrulesignificantlyreducedtherateof transportoffutileOHCAyetalsoledintwoseparatestudiestoan unexpectedsurvivalof3.4%and9%respectivelyinOHCApatients withoutpre-hospitalsustainedROSC.

SomeEMSsystemsusejustthatonecomponent,theabsence ofpre-hospital returnofspontaneouscirculation (ROSC),asthe criteriontoterminateresuscitationandthisclearlymayexclude potentialsurvivorsfortransportation.78,83–87

Patientswithrefractorycardiacarrest,withongoingCPRduring transporttohospital,usedtohaveaverypoorprognosis.88,89Ina

movingvehicle,manualCPRmaybedifficultandtheuseof mechan-icaldevicesmaybeconsidered.Asadvancedrescuetherapiesand specificcircumstances-relatedinterventionsbecomemorewidely availableandsuccessratesareimproving,definingwhichpatients mightbenefitfromthesebecomescrucial.90–92

WithholdingorwithdrawingCPR

Healthcareprofessionalsshouldconsiderwithholdingor with-drawingCPRinchildrenandadultswhen:

• thesafetyoftheprovidercannolongerbesufficientlyassured; • thereisobviousmortalinjuryorirreversibledeath[ROLE];

(5)

• avalidandrelevantadvancedirectivebecomesavailable; • thereisotherstrongevidencethatfurtherCPRwouldbeagainst

patient’svaluesandpreferencesorisconsidered‘futile’; • asystoleformorethan20mindespiteongoingALS,intheabsence

ofareversiblecause.

AfterstoppingCPR,thepossibilityofongoingsupportofthe cir-culationandtransporttoadedicatedcentreinperspectiveoforgan donationshouldbeconsidered.

TransporttohospitalwithongoingCPR

Healthcareprofessionalsshouldconsidertransporttohospital withongoingCPRwhen,in theabsenceoftheaboveCPR with-drawalcriteria,thereisoneormoreofthefollowingpresent: • EMSwitnessedarrest;

• ROSCatanymoment; • VT/VFaspresentingrhythm;

• Presumedreversiblecause(e.g.,cardiac,toxic,hypothermia). Thisdecisionshouldbeconsideredearlyintheprocesse.g.,after 10minofALSwithoutROSCandinviewofthecircumstancese.g., distance,CPRdelayandpresumedCPRqualityinviewofpatient characteristicse.g.,presumedQoL.

Paediatriccardiacarrest

Despitedifferencesinpathophysiologyandaetiology,the ethi-calframeworkfordecision-makinginpaediatriccardiacarrestdoes notdiffermuchfromthatdescribedabove.93,94Mostphysicians

willerrevenmoreonthesideofinterventioninchildrenfor emo-tionalreasonsandcontinuearesuscitationattemptlonger,despite theoverallprognosisinchildrenoftenbeingworsethaninadults. Itisthereforeimportantforclinicianstounderstandthefactors thatinfluenceresuscitationsuccessandtheboundariesofthecare theyprovide.Asinadultpractice,futileresuscitationmightbe con-sidereddysthanasia(mercilessprolongationoflife)andshouldbe avoided.81Thechild’sbestinterestmightsometimesconflictwith

parentorguardian’srights.Fromasocietalperspective,weallow parent’sdecisionstodifferfromso-calledbestintereststandards aslongasnounacceptableharmisdonetothechild.Extrapolating thistothecontextofresuscitation,parent’srightsand decision-makingmightprevailuptothepointwheretherewouldbeharm. Prolongedfutileresuscitationcouldbeanexampleofsuchharm. Providingadequateinformationinaclearbutempathicwayis cru-cialforthisdecision-makingprocess.

Mostcountrieshaveproceduresformedico-legalinvestigation ofSudden UnexplainedDeathOf Infancy(SUDI). In many SUDI casesnofinalcauseis identifiedand deathmight berelatedto anintrinsicvulnerability,developmentalchangesand environmen-talfactors.95Somedeathshowevermightbecausedbyinfection,

neuro-metabolicdisease or by accidental or inflicted injury. In mostcountries,legalauthoritiesareinvolvedincasesofsudden unexplained or accidental death. In some countries systematic review of all child deaths is organised to get a better under-standingandknowledge forthe preventionoffuture children’s deaths.96Althoughtherearestillmajorchallenges,formalchild

deathreviewsmaycontributegreatlytoprevention,caredelivered andfinaloutcomeofpaediatriccardiacarrest.

Specificcircumstances Slowcode

Someprehospitalprovidersfinditdifficulttostop resuscita-tiononcestartedandwouldargueforcontinuingCPR,especially

inyoungpersons,untilarrivaltothehospital.Somedefendthis practiceonthegroundthat,atacertainpoint,the‘bestinterest’ ofthefamilymightstarttooutweighthatofthepatient.97,98This

viewisnotsupportedbyevidence.Inthesettingofpost-traumatic cardiacarrestitseemedthatfamiliesofpatientswhodie out-of-hospitaladaptbettertotheirlosseswhenthereiscessationoffutile resuscitativeeffortsinthefield.93PerformingfutileCPRtoaddress

thegriefandneedsof‘significantothers’isethicallyunsound,being bothdeceptiveandpaternalistic.43

Likewise,certainauthorsarguedinfavourofa‘slowcode’ ini-tiatingsome‘symbolic’resuscitationmeasuresbutunhurriedlyor omittingthemostaggressiveones,sparingphysicianandfamily thehelplessfeelingofdoingnothingandavoidingpotential con-flictor theneedtocommunicate badnews, especiallyin those settingswherethereisnostrongphysician–patientrelationship andaclearlackofinformation.43This‘slowcode’isequally

decep-tiveandpaternalistic,andunderminesboththepatient–physician relationshipandthetrainingandeducationofourteams.93

Avaluablealternativemaybea‘tailoredcode’,wherehigh qual-ityresuscitationisperformedbutclearlimitsaredefined.Family membersareinformedinatransparentwaywhatwillbedoneand

whatnot.99,100

Providersafety

Safety of thehealthcare provider is vitallyimportant. Infec-tiousdiseaseepidemicshaveraisedconcernsaboutthesafetyof healthcareprovidersinvolvedinthecareofcardiacarrestpatients. Specificattention totheuse ofproper protective equipmentis essential,especiallywhenthereisinsufficientinformationabouta patient’shistoryandpotentialinfectiousstate.Todatethereis lit-tleinformationaboutthepreciseriskoftransmissionwhendoing CPRonaninfectiouspatient,andassuch–ifproperlyprotected– providersshouldattemptresuscitationinthesepatients.Possible exemptionstothisstandardrulewouldbethoseinfectionsor situ-ationswhereacleardangerremainsforthehealthcareprovider, even when protected. In these casesthe provider’sown safety would bepriority.WhenattemptingCPRin infectious patients’ healthcare professionals mustuseproper protectiveequipment andbesufficientlytrainedinitsuse.101,102

Resuscitationaftersuicideattempts

Apersonwithmentalillnessisnotnecessarilyconsidered men-tallyincompetentandmayhaveanequalrighttorejectmedical treatmentand opt for palliative care. Based onthe concept of autonomy,onecouldarguethatasuicideattemptmayinitselfbe anexpressionofpersonalpreferences.Inanemergencyitis dif-ficulttoassessmentalcapacityreliablyevenifasuicidenoteis found.Giventhatnon-treatmentleadstoseriousharm,thedefault remainstostartCPRassoonaspossibleandaddresspotentialissues later.103,104

Organdonation

Theprimarygoalofresuscitationistosavethepatient’slife.105

Nonetheless,resuscitationeffortsmayresultinbraindeath.Inthese cases,theaimofresuscitationcouldchangetothepreservationof organsforpossibledonation.106Severalstudieshaveshownthat

theoutcomeoforganstransplantedfrompatientswhoreceived CPRandarebraindeadisnotdifferentfromtheoutcomesoforgans transplantedfrompatientswhohavebeenpronouncedbraindead fromothercauses(seesectiononPostResuscitationCare).107–109

However,theduty of resuscitationteams forthe livingpatient shouldnotbeconfusedwiththedutyofphysiciansforthedead donors,wheretheorgansarepreservedtosaveotherpeople’slives. Ontheotherhand,itisreasonabletosuggestthatallEuropean countriesshouldenhancetheireffortstomaximisethepossibility oforgandonationfromcardiacarrestpatientswhobecamebrain

(6)

deadorafterstoppingresuscitationincaseofCPRfailure.110

Proce-duresshouldensurethatanypossibleinterferenceofthetransplant teaminthedecisionmakingoftheresuscitationteamisavoided.

VariabilityinethicalCPRpracticesinEurope

Tenyears afterareportbyBaskettandLim,111opinion

lead-ers representing 32 Europeancountries where theactivities of theEuropeanResuscitationCouncilareorganised,haveresponded to questions regarding local ethical legislation and practice of resuscitation,andorganisationofout-of-hospitalandin-hospital resuscitationservices.Thesurveymethodsandresultsaredetailed anddiscussedelsewhere.

Thesurveyshowedthatthereisstillawidevariabilityinthe implementationofethicalpracticesinEuropeancountries.

Equalaccesstoemergencycareandtoearlydefibrillationisnow wellestablished:thefirstattendingambulancearrivesatthescene within10mininthemajorityofcountries(18/32inruralareasand 24/32inurbanareas).Defibrillationbythefirstattending ambu-lanceisavailablein29/32countries.

Theprincipleofpatientautonomyisnowlegallysupportedin themajorityofcountries(advancedirectivesin20countriesand DNARin22countries).

However,areasforimprovementwereidentified:inlessthan halfofcountriesfamilymembersareusuallyallowedtobepresent duringCPR(adultin10/32andchildrenin13/32countries).This hasnotsubstantiallychangedinthelast10years.

Atthistimeeuthanasiaandphysician-assistedsuicideare con-troversialsubjectsinmanyEuropeancountriesandthediscussion isongoinginseveralEuropeancountries.

CertainformsoftreatmentlimitationssuchaswithholdingCPR areallowed(19countries) andpracticed(21countries)inmost Europeancountries.

Harmonisationoflegislationrelatingtoresuscitationand end-of-lifewouldfurthersupportethicalpractices.

Healthcareprofessionalsshouldknowandapplytheestablished nationalandlocallegislationandpolicies.

Communication

Familypresenceduringresuscitation

Sincethe1980s,theconceptofafamilymemberbeingpresent attheresuscitationprocessbecameanacceptedpracticeinmany countries.112–116Themajorityofrelativesandparentswhowere

presentduringresuscitationattemptswouldwishtobesoagain.113

ArecentEuropeansurveyreportedthatinonly31%ofcountries family members are usually allowed to be present during in-hospitalresuscitationattemptsofanadultandonlyslightlymore ifthevictimwasachild(41%).

TheERCsupportsrelativesbeingofferedthechoicetobepresent duringaresuscitationattemptwhilstculturalandsocialvariations mustbeunderstoodandappreciatedwithsensitivity.Observing theresuscitation attempt may provide benefit tofamily mem-bersbyreducingguiltordisappointment,allowingtimetoaccept therealityofdeathandhelpthegrievingprocess.Whenpossible, anexperiencedmemberofstaffshouldfacilitateandsupportthe relativeduringtheresuscitationattempt.114,115 Familypresence

duringresuscitationattempts willcontributetoan increasingly openattitudeandappreciationoftheautonomyofbothpatientand relatives.111,112Nodatasupporttheconcernsthatfamilymembers

maybetraumatisedwitnessingCPR,ormayinterferewith med-icalcareprocedures.117 Weshouldfocusoureffortsonworking

togetherwiththesurvivorsofcardiacarrest,familymembersand thepublicaspartnersintheco-productionoffutureguidance.

Bringingbadnewsandbereavementcounselling

Amultidisciplinaryapproachtothecareattheendoflife, includ-ingcommunication,takingintoaccountcultural,social,emotional, religious,spiritualpreferencesandlocaldifferencesneedsfurther developmentandimplementationinhealthcare systems world-wide.

Compassionatecommunicationwithpatientsandlovedonesis essentialwhendealingwithendof-life-care.Theaimisto under-standthepatient’sgoalsandexpectationsofmedicaltreatmentto supporttheindividualchoiceofthebestcare.Somepatientswish toprolonglifeaslongaspossible,whileothersvaluedignityand painreliefevenattheexpenseofapotentiallyshortenedlifetime. Privacyandadequatetimeareessentialforgoodcommunication aboutlifevaluesandsignificantdecisions.118

Multidisciplinarybereavementprogramsarebeneficialto fam-ilies of patientswho die in theemergency department.119 The

grievingprocessmaybesupportedbyallowingunrestricted vis-iting,provisionofclearverbalandwritteninformation,providing the opportunity to visit the deceased and facilitating religious procedures.120,121Patientsandtheirbelovedonesdeserverespect.

Clinicians should be honest about what can and cannot be achieved.Sharingthetruthofthesituationcanactasasymbolic expressionofacomplexsetofcommitments.29Thiswillallowthe

patientstomakeinformeddecisionsaboutthechoicesavailableto themattheendoftheirlives.

DocumentationofDNARorderinthepatient’schart

DNARdecisions and discussionsrelating toDNAR shouldbe recordedclearlyinthepatient’snotes.72,73,122,123Whatever

sys-temisuseditmustbehighlyvisibleinordertoinformpersonnel onthespot.

Overtimethesituationortheperspectivesofpatientsmight changeandDNARordersshouldberevisedaccordingly.124

Exemp-tionsfromDNARordershouldbeclearly specified(e.g.,cardiac arrestcomplicatingdiagnosticprocedures,suchasallergicshock due to radiology dye or intracardiac catheter investigation) to ensurethepatientwillreceiveappropriatetreatment.

Training,researchandaudit

It is the individualresponsibility of healthcare professionals tomaintaintheirknowledge,understandingandskillsrelatedto resuscitation.Theirknowledgeaboutrelevantnationallegaland organisationalpoliciesintheircountryshouldbekeptuptodate. ImprovingpubliceducationregardingCardiopulmonary

Resuscitation

Theshiftfrommedical-centredtopatient-centredpractice con-stitutesamajorethicaldevelopment.Thisrequiresthatthepatient isaware(andnotmisinformed)ofthetruelimitationsandpossible outcomesofresuscitation.125–127 Laypeoplemayhave

unrealis-ticexpectationsfromCPR128,129andexposuretorealisticoutcome

datamayaffectpersonalpreferences.130

TraininghealthcareprofessionalsaboutDNARissues

Healthcareprofessionalsshouldreceivetrainingaboutthelegal andethicalbasisofDNARdecisionsandabouthowtocommunicate effectivelywithpatients,relativesornextofkin.Qualityoflife, supportivecareandend-of-lifedecisionsneedtobeexplainedas anintegrativepartofthemedicalandnursingpractice.131Training

(7)

willneedtobesensitivetopersonal,moralandreligiousbeliefsand feelings.

Practicingproceduresontherecentlydead

Thereisa wide diversityof opinionabout practicingonthe newly dead rangingfrom complete non-acceptancebecause of aninnate respectfor thedeceased132 totheacceptance of

non-invasiveprocedures not leaving major marks.133 Others accept

trainingofanyprocedureondeadbodiesandjustifyskillstraining asparamountforthewell-beingoffuturepatients.134–137

Healthcarestudentsandteachingprofessionalsareadvisedto learnandfollowtheestablishedlegal,regionalandlocalhospital policies.

Researchandinformedconsent

Research in the field of resuscitation is necessary to test commonly used interventions with uncertain efficacy or new potentiallybeneficialtreatments.138,139Toincludeparticipantsin

astudy,informedconsentmustbeobtained.Inemergencies,there is often insufficienttime toobtain informed consent. Deferred consentorexceptiontoinformedconsentwithpriorcommunity consultation,areconsideredethicallyacceptablealternativesfor respectingautonomy.140,141 Following12 years of ambiguity, a

newEuropeanUnion(EU)Regulationpermittingdeferredconsent isexpectedtoharmoniseand fosteremergencyresearchacross MemberStates.139,140,142,143Furtherregulatoryimprovementsare

neededforemergency surgicalresearch144 and forresearching

non-medicinalinterventions.139Despitethisprogress,regulations

stillneedtoconvergeataninternationalleveltoharmonise multi-nationalemergencyresearch.145

Auditofin-hospitalcardiacarrestsandregistryanalyses

Local CPR management can be improvedthrough post-CPR debriefing and feedback to ensure a PDCA (plan-do-check-act) circle of quality improvement. Debriefing and feedback enablesidentification of CPR quality errors and prevents their repetition.146–148SubmissionofCPRdatatonationalauditsand/or

international registries has led to outcome-prediction models, whichmayfacilitateadvancecareplanning149–153,andto

quan-tification of the frequency of resuscitation system errors and theirimpactonin-hospitalmortality.154Datafromregistrieshave

shownsignificantimprovementsincardiacarrestoutcomesfrom 2000to2010.3,155–157

Published evidence suggests that resuscitation team-based infrastructure and multilevel institutional audit,158 accurate

reporting54 of resuscitation attempts at national audit level

and/ormultinationalregistrylevel,andsubsequentdataanalysis andfeedback fromreportedresultsmay contributeto continu-ous improvement of in-hospital CPR quality and cardiac arrest outcomes.2,3,159–161

Collaborators

MariosGeorgiou,AmericanMedicalCenter,UniversityofNikosia, Cyprus

FreddyK.Lippert,EmergencyMedicalServicesCopenhagen, Univer-sityofCopenhagen,Denmark

PetterA.Steen,UniversityofOslo,OsloUniversityHospitalUlleval, Oslo,Norway.

Conflictsofinterest

LeoL.Bossaert Noconflictofinterestreported GavinD.Perkins EditorResuscitation HelenAskitopoulou Noconflictofinterestreported JerryP.Nolan Editor-in-ChiefResuscitation KirstieL.Haywood Noconflictofinterestreported PatrickVandeVoorde Noconflictofinterestreported RobertGreif Noconflictofinterestreported SpyrosD.Mentzelopoulos Noconflictofinterestreported ViolettaI.Raffay Noconflictofinterestreported TheodorosT.Xanthos PresidentHellenicSocietyCPR

www.EEKA.gr,Labresearch grantsELPENPharma

Acknowledgements

TheauthorsthankHilaryPhelanforherprofessionalsupport inpreparingtheon-linequestionnairefortheEuropeanSurveyon EthicalPracticesandfororganisingthedatainadedicateddatabase. TheauthorsthankallcontributorstotheEuropeanSurveyon EthicalPractices:M.Baubin,A.Caballero,P.Cassan,G.Cebula,A. Certug,D.Cimpoesu,S.Denereaz,C.Dioszeghy,M.Filipovic,Z.Fiser, M.Georgiou,E.Gomez,P.Gradisel,JT.Gräsner,R.Greif,H.Havic,S. Hoppu,S.Hunyadi,M.Ioannides,J.Andres,J.Joslin,D.Kiss,J.Köppl, P.Krawczyk,K.Lexow,F.Lippert,S.Mentzelopoulos,P.Mols,N. Mpotos,P.Mraz,V.Nedelkovska,H.Oddsson,D.Pitcher,V.Raffay, P.Stammet,F.Semeraro,A.Truhlar,H.VanSchuppen,D.Vlahovic, A.Wagner.

References

1.BerdowskiJ,BergRA,TijssenJG,KosterRW.Globalincidencesof out-of-hospitalcardiacarrestandsurvivalrates:systematicreviewof67prospective studies.Resuscitation2010;81:1479–87.

2.McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance—cardiacarrestregistrytoenhancesurvival(CARES),60.United States:MMWRSurveillanceSummaries;2011.p.1–19.

3.DayaMR,SchmickerRH,ZiveDM,etal.Out-of-hospitalcardiacarrest sur-vivalimprovingovertime:resultsfromtheresuscitationoutcomesconsortium (ROC).Resuscitation2015;91:108–15.

4.SassonC,RogersMA,DahlJ,KellermannAL.Predictorsofsurvivalfrom out-of-hospitalcardiacarrest:asystematicreviewandmeta-analysis.CircCardiovasc QualOutcomes2010;3:63–81.

5.KolteD, KheraS,AronowWS, etal. Regionalvariation intheincidence andoutcomesofin-hospitalcardiacarrestintheUnitedStates.Circulation 2015;131:1415–25.

6.NicholsM,TownsendN,ScarboroughP,RaynerM.Cardiovasculardiseasein Europe:epidemiologicalupdate.EurHeartJ2013;34:3028–34.

7.Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015update:areportfromtheAmericanHeartAssociation. Cir-culation2015;131:e29–322.

8.WissenbergM,LippertFK,FolkeF,etal.Associationofnationalinitiativesto improvecardiacarrestmanagementwithratesofbystanderinterventionand patientsurvivalafterout-of-hospitalcardiacarrest.JAMA2013;310:1377–84.

9.HollerNG,MantoniT,NielsenSL,LippertF,RasmussenLS.Long-termsurvival afterout-of-hospitalcardiacarrest.Resuscitation2007;75:23–8.

11.BeauchampTL,ChildressJF.Principlesofbiomedicalethics.6thed.NewYork: OxfordUniversityPress;2009.

12.EnglishV,SommervilleA.Medicalethicstoday:theBMA’shandbookofethics andlaw.2nded.London:BMJBooks;2004.

13.MarcoCA,MarcoCA.Ethicalissuesofresuscitation:anAmericanperspective. PostgradMedJ2005;81:608–12.

14.KaldjianLC,WeirRF,DuffyTP.Aclinician’sapproachtoclinicalethical reason-ing.JGenInternMed2005;20:306–11.

15.O’NeillO.Autonomyandtrustinbioethics.Cambridge,NewYork:Cambridge UniversityPress;2002.

16.WorldMedicalAssociation.Medicalethicsmanual.secondednFerney-Voltaire Cedex:TheWorldMedicalAssociation;2009.

17.RysavyM.Evidence-basedmedicine:ascienceofuncertaintyandanartof probability.VirtualMentor2013;15:4–8.

18.ChristinePJ,KaldjianLC.Communicatingevidenceinshareddecisionmaking. VirtualMentor2013;15:9–17.

19.CouncilofEurope.Biomedicinehumanrights—theOviedoconventionits addi-tionalprotocols.Strasbourg:CouncilofEurope;2010.

(8)

20.SoreideE,MorrisonL,HillmanK,etal.Theformulaforsurvivalinresuscitation. Resuscitation2013;84:1487–93.

21.LippertFK,RaffayV,GeorgiouM,SteenPA,BossaertL.EuropeanResuscitation Councilguidelinesforresuscitation2010Section10.Theethicsofresuscitation andend-of-lifedecisions.Resuscitation2010;81:1445–51.

22.MorrisonLJ,KierzekG,DiekemaDS,etal.Part3:ethics:2010Americanheart associationguidelinesforcardiopulmonaryresuscitationandemergency car-diovascularcare.Circulation2010;122:S665–75.

23.NationalInstituteforHealthandClinicalExcellence.HowNICEclinical guide-linesaredeveloped:anoverviewforstakeholders,thepublicandtheNHS.In: ProcessandMethodsGuides.5theditionLondon:NationalInstituteforHealth andClinicalExcellence;2012.

24.BrodyBA,HalevyA.Isfutilityafutileconcept?JMedPhilos1995;20:123–44.

25.SwigL,CookeM,OsmondD,etal.Physicianresponsestoahospitalpolicy allowingthemtonotoffercardiopulmonaryresuscitation.JAmGeriatrSoc 1996;44:1215–9.

26.TruogRD, Brett AS, FraderJ. The problemwith futility. N Engl J Med 1992;326:1560–4.

27.SandroniC,CariouA,CavallaroF,etal.Prognosticationincomatosesurvivors ofcardiacarrest:anadvisorystatementfromtheEuropeanResuscitation CouncilandtheEuropeanSocietyofIntensiveCareMedicine.Resuscitation 2014;85:1779–89.

28.FraderJ,KodishE,LantosJD.Ethicsrounds.Symbolicresuscitation,medical futility,andparentalrights.Pediatrics2010;126:769–72.

29.LantosJD,MeadowWL.Shouldthe“slowcode”beresuscitated?AmJBioethics 2011;11:8–12.

30.ChuK,SworR,JacksonR,etal.Raceandsurvivalafterout-of-hospitalcardiac arrestinasuburbancommunity.AnnEmergMed1998;31:478–82.

31.VaillancourtC,LuiA,DeMaioVJ,WellsGA,StiellIG.Socioeconomicstatus influencesbystanderCPRandsurvivalratesforout-of-hospitalcardiacarrest victims.Resuscitation2008;79:417–23.

32.FolkeF,GislasonGH,LippertFK,etal.Differencesbetweenout-of-hospital cardiacarrestinresidentialandpubliclocationsandimplicationsfor public-accessdefibrillation.Circulation2010;122:623–30.

33.AhnKO,ShinSD,HwangSS,etal.Associationbetweendeprivationstatusat communitylevelandoutcomesfromout-of-hospitalcardiacarrest:a nation-wideobservationalstudy.Resuscitation2011;82:270–6.

34.AufderheideTP,NolanJP,JacobsIG,etal.Globalhealthandemergencycare:a resuscitationresearchagenda–part1.AcadEmergMed2013;20:1289–96.

35.SassonC,MagidDJ,ChanP,etal.Associationofneighborhoodcharacteristics withbystander-initiatedCPR.NEnglJMed2012;367:1607–15.

36.SempleHM,CudnikMT,SayreM,etal.Identificationofhigh-riskcommunities forunattendedout-of-hospitalcardiacarrestsusingGIS.JCommunityHealth 2013;38:277–84.

37.RahimiAR,SpertusJA,ReidKJ,BernheimSM,KrumholzHM.Financial bar-rierstohealthcareandoutcomesafteracutemyocardialinfarction.JAMA 2007;297:1063–72.

38.RootED,GonzalesL,PersseDE,HincheyPR,McNallyB,SassonC.Ataleoftwo cities:theroleofneighborhoodsocioeconomicstatusinspatialclusteringof bystanderCPRinAustinandHouston.Resuscitation2013;84:752–9.

39.YusufS,RangarajanS,TeoK,etal.Cardiovascularriskandeventsin17low-, middle-,andhigh-incomecountries.NEnglJMed2014;371:818–27.

40.WaiselDB,TruogRD.Thecardiopulmonaryresuscitation-not-indicatedorder: futilityrevisited.AnnInternMed1995;122:304–8.

41.BritishMedicalAssociation,TheResuscitationCouncil(UK),TheRoyal Col-legeofNursing.Decisionsrelatingtocardiopulmonaryresuscitation.Ajoint statmentfrom theBritish Medical Association,theResuscitation Council (UK)andtheRoyalCollegeofNursing.London:BritishMedicalAssociation; 2014.

42.SoholmH,Bro-JeppesenJ,LippertFK,etal.Resuscitationofpatients suffer-ingfromsuddencardiacarrestsinnursinghomesisnotfutile.Resuscitation 2014;85:369–75.

43.BremerA,SandmanL.Futilecardiopulmonaryresuscitationforthebenefitof others:anethicalanalysis.NursEthics2011;18:495–504.

44.CommitteeonBioethics(DH-BIO)oftheCouncilofandEurope.Guideonthe decision-makingprocessregardingmedicaltreatmentinend-of-lifesituations. Strasbourg:CouncilofEurope;2014.

45.FritzZ,CorkN,DoddA,MalyonA.DNACPRdecisions:challengingandchanging practiceinthewakeoftheTraceyjudgment.ClinMed2014;14:571–6.

46.EtheridgeZ,GatlandE.Whenandhowtodiscuss“donotresuscitate”decisions withpatients.BMJ2015;350:h2640.

47.BlindermanCD,KrakauerEL,SolomonMZ.Timetorevisetheapproachto determiningcardiopulmonaryresuscitationstatus.JAMA2012;307:917–8.

48.XanthosT.‘Donotattemptcardiopulmonaryresuscitation’or‘allowingnatural death’?Thetimeforresuscitationcommunitytoreviewitsboundariesandits terminology.Resuscitation2014;85:1644–5.

49.SalkicA,ZwickA.Acronymsofdyingversuspatientautonomy.EurJHealth Law2012;19:289–303.

50.JohnstonC,LiddleJ.TheMentalCapacityAct2005:anewframeworkfor healthcaredecisionmaking.JMedEthics2007;33:94–7.

51.AndornoR,Biller-AndornoN,BrauerS.Advancehealthcaredirectives:towards acoordinatedEuropeanpolicy?EurJHealthLaw2009;16:207–27.

52.ShawD.Adirectadvanceonadvancedirectives.Bioethics2012;26:267–74.

53.ResuscitationCouncil(UK).QualityStandardsforcardiopulmonary resusci-tationpracticeandtraining.Acutecare.London,UK:ResuscitationCouncil; 2013.

54.PerkinsGD, JacobsIG,NadkarniVM, etal. Cardiacarrestand cardiopul-monaryresuscitationoutcomereports:updateoftheUtsteinresuscitation registrytemplatesforout-of-hospitalcardiacarrest.Resuscitation2015;96: 328–40.

55.HaywoodKL,WhiteheadL,PerkinsGD.Thepsychosocialoutcomesofcardiac arrest:relevantandrobustpatient-centredassessmentisessential. Resuscita-tion2014;85:718–9.

56.WhiteheadL,PerkinsGD,ClareyA,HaywoodKL.Asystematicreviewofthe outcomesreportedincardiacarrestclinicaltrials:theneedforacoreoutcome set.Resuscitation2015;88:150–7.

57.BeesemsSG,WittebroodKM,deHaanRJ,KosterRW.Cognitivefunctionand qualityoflifeaftersuccessfulresuscitationfromcardiacarrest.Resuscitation 2014;85:1269–74.

58.MoulaertVRMP,VerbuntJA,vanHeugtenCM,WadeDT.Cognitiveimpairments insurvivorsofout-of-hospitalcardiacarrest:asystematicreview. Resuscita-tion2009;80:297–305.

59.StaniszewskaS,HaywoodKL,BrettJ,TuttonL.Patientandpublic involve-mentinpatient-reportedoutcomemeasures:evolutionnotrevolution.Patient 2012;5:79–87.

60.LiljaG,NielsenN,FribergH,etal.Cognitivefunctioninsurvivorsof out-of-hospitalcardiacarrestaftertargettemperaturemanagementat33◦Cversus

36◦C.Circulation2015;131:1340–9.

61.WachelderEM,MoulaertVR,vanHeugtenC,VerbuntJA,BekkersSC,Wade DT.Lifeaftersurvival:long-termdailyfunctioningandqualityoflifeafteran out-of-hospitalcardiacarrest.Resuscitation2009;80:517–22.

62.SmithK,AndrewE,LijovicM,NehmeZ,BernardS.Qualityoflifeand func-tionaloutcomes12monthsafterout-of-hospitalcardiacarrest.Circulation 2015;131:174–81.

63.KragholmK,WissenbergM,MortensenRN,etal.Returntoworkin out-of-hospitalcardiacarrestsurvivors:anationwideregister-basedfollow-upstudy. Circulation2015;131:1682–90.

64.NakamuraF,HayashinoY,NishiuchiT,etal.Contributionofout-of-hospital factorstoareductionincardiacarrestmortalityafterwitnessedventricular fibrillationortachycardia.Resuscitation2013;84:747–51.

65.Meyer L,Stubbs B,Fahrenbruch C, etal. Incidence, causes,and survival trendsfrom cardiovascular-relatedsuddencardiacarrestinchildrenand youngadults0to35yearsofage:a30-yearreview.Circulation2012;126: 1363–72.

66.BardaiA,BerdowskiJ,vanderWerfC,etal.Incidence,causes,andoutcomes of out-of-hospital cardiac arrestin children. A comprehensive, prospec-tive,population-basedstudyintheNetherlands.JAmCollCardiol2011;57: 1822–8.

67.PerkinsGD,CookeMW.Variabilityincardiacarrestsurvival:theNHS Ambu-lanceServiceQualityIndicators.EmergMedJEMJ2012;29:3–5.

68.FothergillRT,WatsonLR,ChamberlainD,VirdiGK,MooreFP,WhitbreadM. Increasesinsurvivalfromout-of-hospitalcardiacarrest:afiveyearstudy. Resuscitation2013;84:1089–92.

69.HasegawaK,HiraideA,ChangY,BrownDF.Associationofprehospitaladvanced airwaymanagementwithneurologicoutcomeandsurvivalinpatientswith out-of-hospitalcardiacarrest.JAMA2013;309:257–66.

70.VandeVoordeP,MonsieursKG,PerkinsGD,CastrenM.Lookingoverthewall: usingaHaddonmatrixtoguidepublicpolicymakingontheproblemofsudden cardiacarrest.Resuscitation2014;85:602–5.

71.MockfordC,FritzZ,GeorgeR,etal.Donotattemptcardiopulmonary resusci-tation(DNACPR)orders:asystematicreviewofthebarriersandfacilitatorsof decision-makingandimplementation.Resuscitation2015;88:99–113.

72.Field RA, Fritz Z, Baker A, Grove A, Perkins GD. Systematic review of interventions to improve appropriate use and outcomes associated withdo-not-attempt-cardiopulmonary-resuscitationdecisions.Resuscitation 2014;85:1418–31.

73.FreemanK,FieldRA,PerkinsGD. Variationinlocaltrustdonot attempt cardiopulmonaryresuscitation(DNACPR)policies: areview of48english healthcaretrusts.BMJOpen2015;5:e006517.

74.ClementsM,FuldJ,FritzZ.Documentationofresuscitationdecision-making: asurveyofpracticeintheUnitedKingdom.Resuscitation2014;85:606–11.

75.EbellMH,AfonsoAM,GeocadinRG.Americanheartassociation’sgetwiththe guidelines-resuscitationI.Predictionofsurvivaltodischargefollowing car-diopulmonaryresuscitationusingclassificationandregressiontrees.CritCare Med2013;41:2688–97.

76.LannonR, O’Keeffe ST.Cardiopulmonary resuscitationin olderpeople—a review.RevClinGerontol2010;20:20–9.

77.GoldbergerZD, ChanPS,BergRA,et al.Durationofresuscitation efforts andsurvivalafterin-hospitalcardiacarrest:anobservationalstudy.Lancet 2012;380:1473–81.

78.BeckerTK,Gausche-HillM,AsweganAL,etal.Ethicalchallengesinemergency medicalservices:controversiesandrecommendations.PrehospDisasterMed 2013;28:488–97.

79.NordbyH,NohrO.Theethicsofresuscitation:howdoparamedicsexperience ethicaldilemmaswhenfacedwithcancerpatientswithcardiacarrest?Prehosp DisasterMed2012;27:64–70.

80.RanolaPA,MerchantRM,PermanSM,etal.Howlongislongenough,and havewedoneeverythingweshould?Ethicsofcallingcodes.JMedEthics 2014;41:663–6.

81.MercurioMR,MurrayPD,GrossI.Unilateralpediatric“donotattempt resus-citation”orders:thepros, thecons,andaproposedapproach. Pediatrics 2014;133:S37–43[Suppl1].

(9)

82.LevinsonM,MillsA.Cardiopulmonaryresuscitation—timeforachangeinthe paradigm?MedJAust2014;201:152–4.

83.MorrisonLJ,VerbeekPR,ZhanC,KissA,AllanKS.Validationofauniversal prehospitalterminationofresuscitationclinicalpredictionruleforadvanced andbasiclifesupportproviders.Resuscitation2009;80:324–8.

84.SkrifvarsMB,VayrynenT,KuismaM,etal.ComparisonofHelsinkiand Euro-peanResuscitationCouncil“donotattempttoresuscitate”guidelines,anda terminationofresuscitationclinicalpredictionruleforout-of-hospitalcardiac arrestpatientsfoundinasystoleorpulselesselectricalactivity.Resuscitation 2010;81:679–84.

85.DiskinFJ,Camp-RogersT,PeberdyMA,OrnatoJP,KurzMC.Externalvalidation ofterminationofresuscitationguidelinesinthesettingofintra-arrestcold saline,mechanicalCPR,andcomprehensivepostresuscitationcare. Resuscita-tion2014;85:910–4.

86.MorrisonLJ,EbyD,VeigasPV,etal.Implementationtrialofthebasiclife supportterminationofresuscitationrule:reducingthetransportoffutile out-of-hospitalcardiacarrests.Resuscitation2014;85:486–91.

87.DrennanIR,LinS,SidalakDE,MorrisonLJ.Survivalratesinout-of-hospital cardiacarrestpatients transportedwithoutprehospital returnof sponta-neous circulation: an observationalcohort study. Resuscitation2014;85: 1488–93.

88.KellermannAL,HackmanBB,SomesG.Predictingtheoutcomeofunsuccessful prehospitaladvancedcardiaclifesupport.JAMA1993;270:1433–6.

89.OlasveengenTM,WikL,SteenPA.Qualityofcardiopulmonaryresuscitation beforeandduringtransportinout-of-hospitalcardiacarrest.Resuscitation 2008;76:185–90.

90.ZiveD,KoprowiczK,SchmidtT,etal.Variationinout-of-hospitalcardiacarrest resuscitationandtransportpracticesintheresuscitationoutcomes consor-tium:ROCepistry-cardiacarrest.Resuscitation2011;82:277–84.

91.SassonC,HeggAJ,MacyM,ParkA,KellermannA,McNallyB.Prehospital ter-minationofresuscitationincasesofrefractoryout-of-hospitalcardiacarrest. JAMA2008;300:1432–8.

92.StubD,BernardS,PellegrinoV,etal.Refractorycardiacarresttreatedwith mechanicalCPR,hypothermia,ECMOandearlyreperfusion(theCHEERtrial). Resuscitation2015;86:88–94.

93.Fallat M,AmericanCollege of SurgeonsCommittee, AmericanCollege of Emergency Physicians, National Association of EMS, American Academy of Pediatrics. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014;133: e1104–16.

94.LarcherV,CraigF,BhogalK,etal.Makingdecisionstolimittreatmentin life-limitingandlife-threateningconditionsinchildren:aframeworkforpractice. ArchDisChild2015;100:s3–23[Suppl2],PublishedOnlineFirst:19February 2015.

95.FlemingPJ,BlairPS,PeaseA.Suddenunexpecteddeathininfancy:aetiology, pathophysiology,epidemiologyandpreventionin2015.ArchDisChild2015.

96.FraserJ,SidebothamP,FrederickJ,CovingtonT,MitchellEA.Learningfrom childdeathreviewintheUSA,England,Australia,andNewZealand.Lancet 2014;384:894–903.

97.TruogRD,MillerFG.Counterpoint:aredonorsaftercirculatorydeathreally dead,anddoesitmatter?Noandnotreally.Chest2010;138:16–8[discussion 8–9].

98.ParisJJ,AngelosP,SchreiberMD.Doescompassionforafamilyjustifyproviding futileCPR?JPerinatol:OffJCaliforniaPerinatAssoc2010;30:770–2.

99.SandersA,ScheppM,BairdM.Partialdo-not-resuscitateorders:ahazardto patientsafetyandclinicaloutcomes?CritCareMed2011;39:14–8.

100.FormanEN,LaddRE.Whynotaslowcode?VirtualMentor2012;14:759–62.

101.UlrichCM,GradyC.CardiopulmonaryresuscitationforEbolapatients:ethical considerations.NursOutlook2015;63:16–8.

102.Torabi-PariziP,DaveyJrRT,SuffrediniAF,ChertowDS.Ethicalandpractical considerationsinprovidingcriticalcaretopatientswithebolavirusdisease. Chest2015;147:1460–6.

103.DavidAS,HotopfM,MoranP,OwenG,SzmuklerG,RichardsonG.Mentally disorderedorlackingcapacity?Lessonsformanagementofseriousdeliberate selfharm.BMJ2010;341:c4489.

104.SontheimerD.Suicidebyadvancedirective?JMedEthics2008;34:e4.

105.ZavalkoffSR,ShemieSD.Cardiopulmonaryresuscitation:savinglifethen sav-ingorgans?CritCareMed2013;41:2833–4.

106.Orioles A,Morrison WE, Rossano JW, etal. Anunder-recognized bene-fitofcardiopulmonaryresuscitation:organtransplantation.CritCareMed 2013;41:2794–9.

107.AliAA,LimE,ThanikachalamM,etal.Cardiacarrestintheorgandonordoes notnegativelyinfluencerecipientsurvivalafterhearttransplantation.EurJ CardiothoracSurg2007;31:929–33.

108.MatsumotoCS,KaufmanSS,GirlandaR,etal.Utilizationofdonorswhohave sufferedcardiopulmonaryarrestandresuscitationinintestinal transplanta-tion.Transplantation2008;86:941–6.

109.DhitalKK,IyerA,ConnellanM,etal.Adulthearttransplantationwithdistant procurementandex-vivopreservationofdonorheartsaftercirculatorydeath: acaseseries.Lancet2015;385:2585–91.

110.Gillett G. Honouring the donor: in death and in life. J Med Ethics 2013;39:149–52.

111.BaskettPJ,LimA.ThevaryingethicalattitudestowardsresuscitationinEurope. Resuscitation2004;62:267–73.

112.DoyleCJ,PostH,BurneyRE,MainoJ,KeefeM,RheeKJ.Familyparticipation duringresuscitation:anoption.AnnEmergMed1987;16:673–5.

113.BoieET,MooreGP,BrummettC,NelsonDR.Doparentswanttobepresent duringinvasiveproceduresperformedontheirchildrenintheemergency department?Asurveyof400parents.AnnEmergMed1999;34:70–4.

114.EichhornDJ,MeyersT,GuzzettaCE,etal.Familypresenceduringinvasive pro-ceduresandresuscitation:hearingthevoiceofthepatient.AJNAmJNurs 2001;101:48–55.

115.WagnerJM.Livedexperienceofcriticallyillpatientsfamilymembersduring cardiopulmonaryresusitation.AJCC2004;13:416–20.

116.JabreP,TazarourteK,AzoulayE,etal.Offeringtheopportunityforfamilytobe presentduringcardiopulmonaryresuscitation:1-yearassessment.Intensive CareMed2014;40:981–7.

117.RobinsonSM,Mackenzie-RossS,CampbellHewsonGL,EglestonCV,PrevostAT. Psychologicaleffectofwitnessedresuscitationonbereavedrelatives.Lancet 1998;352:614–7.

118.FallowfieldLJ,JenkinsVA,BeveridgeHA.Truthmayhurtbutdeceithurtsmore: communicationinpalliativecare.PalliatMed2002;16:297–303.

119.LeBrocqP,CharlesA,ChanT,BuchananM.Establishingabereavement pro-gram:caringforbereavedfamiliesandstaffintheemergencydepartment. AccidEmergNurs2003;11:85–90.

120.RabowMW,HauserJM,AdamsJ.Supportingfamilycaregiversattheendof life:“theydon’tknowwhattheydon’tknow”.JAMA2004;291:483–91.

121.OlsenJC,BuenefeML,FalcoWD.Deathintheemergencydepartment.Ann EmergMed1998;31:758–65.

122.HurstSA,BecerraM,PerrierA,PerronNJ,CochetS,ElgerB.Includingpatients inresuscitationdecisionsinSwitzerland:fromdoingmoretodoingbetter.J MedEthics2013;39:158–65.

123.GortonAJ,JayanthiNV,LeppingP,ScrivenMW.Patients’attitudestowards“do notattemptresuscitation”status.JMedEthics2008;34:624–6.

124.MicallefS,SkrifvarsMB,ParrMJ.Levelofagreementonresuscitation deci-sionsamonghospitalspecialistsandbarrierstodocumentingdonotattempt resuscitation(DNAR)ordersinwardpatients.Resuscitation2011;82:815–8.

125.HorburgerD,HaslingerJ,BickelH,etal.Wherenoguidelinehasgonebefore: retrospective analysisofresuscitation in the24th century.Resuscitation 2014;85:1790–4.

126.HinkelbeinJ, SpeltenO, Marks J,HellmichM,BottigerBW,WetschWA. Anassessmentofresuscitationqualityinthetelevisiondramaemergency room:guidelinenon-complianceandlow-qualitycardiopulmonary resusci-tationleadtoafavorableoutcome?Resuscitation2014;85:1106–10.

127.DiemSJ,LantosJD,TulskyJA.Cardiopulmonaryresuscitationontelevision. Miraclesandmisinformation.NEnglJMed1996;334:1578–82.

128.RobertsD, HirschmanD,ScheltemaK.AdultandpediatricCPR:attitudes andexpectationsofhealthprofessionalsandlaypersons.AmJEmergMed 2000;18:465–8.

129.JonesGK,BrewerKL,GarrisonHG.Publicexpectationsofsurvivalfollowing cardiopulmonaryresuscitation.AcadEmergMed:OffJSocAcadEmergMed 2000;7:48–53.

130.MarcoCA,LarkinGL.Publiceducationregardingresuscitation:effectsofa multimediaintervention.AnnEmergMed2003;42:256–60.

131.PitcherD,SmithG,NolanJ,SoarJ.ThedeathofDNR.Trainingisneededto dispelconfusionaroundDNAR.BMJ2009;338:b2021.

132.BülowH-H,SprungC,ReinhartK,etal.Theworld’smajorreligions’pointsof viewonend-of-lifedecisionsintheintensivecareunit.IntensiveCareMed 2008;34:423–30.

133.BergerJT,RosnerF,CassellEJ.Ethicsofpracticingmedicalproceduresonnewly deadandnearlydeadpatients.JGenInternMed2002;17:774–8.

134.MoragRM,DeSouzaS,SteenPA,etal.Performingproceduresonthenewly deceasedforteachingpurposes:whatifweweretoask?ArchInternMed 2005;165:92–6.

135.FourreMW.Theperformanceofproceduresontherecentlydeceased.Acad EmergMed:OffJSocAcadEmergMed2002;9:595–8.

136.MakowskiAL.Theethicsofusingtherecently deceasedto instruct resi-dentsincricothyrotomy.AnnEmergMed2015,http://dx.doi.org/10.1016/ j.annemergmed.2014.11.019, pii: S0196-0644(14)01560-1,[Epubahead of print].

137.HergenroederGW,PratorBC,ChowAF,PownerDJ.Postmortemintubation training:patientandfamilyopinion.MedEduc2007;41:1210–6.

138.DaviesH,ShakurH,PadkinA,RobertsI,SlowtherAM,PerkinsGD.Guidetothe designandreviewofemergencyresearchwhenitisproposedthatconsentand consultationbewaived.EmergMedJEMJ2014;31:794–5.

139.MentzelopoulosSD,MantzanasM,vanBelleG,NicholG.EvolutionofEuropean Unionlegislationonemergencyresearch.Resuscitation2015;91:84–91.

140.BoothMG.Informedconsentinemergencyresearch:acontradictioninterms. SciEngEthics2007;13:351–9.

141.WorldMedicalAssociation.Declarationofhelsinki:ethicalprinciplesfor med-icalresearchinvolvinghumansubjects.JAMA2013;310:2191–4.

142.PerkinsGD,BossaertL,NolanJ,etal.ProposedrevisionstotheEUclinicaltrials directive—commentsfromtheEuropeanResuscitationCouncil.Resuscitation 2013;84:263–4.

143.LemaireF.ClinicalresearchintheICU:responsetoKompanjeetal.Intensive CareMed2014;40:766.

144.CoatsTJ.Barriers,regulationsandsolutionsinemergencysurgeryresearch.Br JSurg2014;101:e3–4.

145.vanBelleG, MentzelopoulosSD, AufderheideT, MayS,NicholG. Inter-nationalvariationinpoliciesandpracticesrelatedtoinformedconsentin acutecardiovascularresearch:resultsfroma44countrysurvey.Resuscitation 2015;91:76–83.

(10)

146.Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrestprocessandoutcomeswithperformancedebriefing.ArchInternMed 2008;168:1063–9.

147.McInnesAD,SuttonRM,NishisakiA,etal.Abilityofcodeleaderstorecall CPRqualityerrorsduringtheresuscitationofolderchildrenandadolescents. Resuscitation2012;83:1462–6.

148.WolfeH,ZebuhrC,TopjianAA,etal.InterdisciplinaryICUcardiacarrest debrief-ingimprovessurvivaloutcomes*.CritCareMed2014;42:1688–95.

149.NolanJP,SoarJ,SmithGB,etal.Incidenceandoutcomeofin-hospital car-diacarrestintheUnitedKingdomnationalcardiacarrestaudit.Resuscitation 2014;85:987–92.

150.HarrisonDA,PatelK,NixonE,etal.Developmentandvalidationofriskmodels topredictoutcomesfollowingin-hospitalcardiacarrestattendedbya hospital-basedresuscitationteam.Resuscitation2014;85:993–1000.

151.Chan PS, Berg RA, Spertus JA, et al. Risk-standardizing survival for in-hospitalcardiacarresttofacilitatehospitalcomparisons.JAmCollCardiol 2013;62:601–9.

152.ChanPS,SpertusJA,KrumholzHM,etal.Avalidatedpredictiontoolforinitial survivorsofin-hospitalcardiacarrest.ArchInternMed2012;172:947–53.

153.LarkinGL,CopesWS,NathansonBH,KayeW.Pre-resuscitationfactors asso-ciatedwithmortalityin49,130casesofin-hospitalcardiacarrest:areport fromthenationalregistryforcardiopulmonaryresuscitation.Resuscitation 2010;81:302–11.

154.OrnatoJP,PeberdyMA,ReidRD,FeeserVR,DhindsaHS.Impactof resuscita-tionsystemerrorsonsurvivalfromin-hospitalcardiacarrest.Resuscitation 2012;83:63–9.

155.GirotraS,NallamothuBK,SpertusJA,etal.Trendsinsurvivalafterin-hospital cardiacarrest.NEnglJMed2012;367:1912–20.

156.GirotraS,CramP,SpertusJA,etal.Hospitalvariationinsurvivaltrendsfor in-hospitalcardiacarrest.JAmHeartAssoc2014;3:e000871.

157.GirotraS,SpertusJA,LiY,etal.Survivaltrendsinpediatricin-hospitalcardiac arrests:ananalysisfromGetWiththeGuidelines-Resuscitation.Circ Cardio-vascQualOutcomes2013;6:42–9.

158.GabbottD,SmithG,MitchellS,etal.Cardiopulmonaryresuscitation stan-dardsforclinicalpracticeandtrainingintheUK.Resuscitation2005;64: 13–9.

159.GrasnerJT,HerlitzJ,KosterRW,Rosell-OrtizF,StamatakisL,BossaertL. Qual-itymanagementinresuscitation—towardsaEuropeancardiacarrestregistry (EuReCa).Resuscitation2011;82:989–94.

160.GrasnerJT,Bossaert L.Epidemiology andmanagement ofcardiacarrest: what registriesare revealing.Best Pract Res Clin Anaesthesiol 2013;27: 293–306.

161.WnentJ,MastersonS,GrasnerJT,etal.EuReCaONE—27Nations,ONEEurope, ONERegistry:aprospectiveobservationalanalysisoveronemonthin27 resus-citationregistriesinEurope—theEuReCaONEstudyprotocol.ScandJTrauma, ResuscitationEmergMed2015;23:7.

Références

Documents relatifs

lowest frequency subband (e.g. Note that if we utilize all the data for DWT -1 we get a PSNR of 37.32 dB for the resultant texture image which is understandable since we had

Secondly, by setting ambitious energy targets (e.g. bring access to modern energy to an additional 100 million Africans by 2020 ) and by opening EU financial support for

Fondamento della pronuncia è la vieta questione, accennata e della quale si scriverà oltre, circa la menzionata qualificazione di norme di grande riforma economico-sociale del

La compatibilité de l’exception nationale avec les droits garantis par la Convention et ses protocoles ainsi que les standards également dégagés par la Cour

qualité », s'articule autour des principes de nécessité, d'efficacité, de hiérarchie et d'accès au droit. Pour le Conseil constitutionnel, la qualité de la loi suppose le

nanolithography and sample derivatization with amine 4 The sample of 11-undecenyltrichlorosilane SAM was installed in the sample holder, the AFM cell was lled with MeCN and the

Le temps justement – et peut-être plus encore que le traitement de la Guerre de Sécession – est ce qui donne aux œuvres de Julien Green une approche résolument