• M Mohr and D Kettler.
• Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität Göttingen.
• Zentralbl Chir. 1998 Jan 1;123(1):58-65.

AbstractOut-of-hospital emergency medicine, just like any other medical field, must be guided by general ethical principles of medical action. These include respecting the patient's autonomous decision, acting for his benefit, avoiding harm, and justice in distributing the available means. The confrontation with ethical conflicts in the routine of emergency medicine is illustrated by a case report. The emergency physician, called to a 76-year-old patient with circulatory arrest, decides against starting a resuscitation attempt. His decision is based on the fact that at least 15 minutes had passed from the cardiac arrest till the arrival of the emergency care team, on the previously existing, severe cardiac disease, on the age of the patient, on family statements of patient's refusal of resuscitation and on the clinical findings of fixed, dilated pupils, missing brainstem reflexes, and an asystole as an initially recorded cardiac rhythm. No certain clinical signs of death could be observed. In the face of this combination of conditions unfavourable for a successful resuscitation attempt and a survival of the patient, the emergency physician assumes an obvious futility of medical action. The individual criteria are analysed with respect to their prognostic value for estimating the chances of surviving out-of-hospital circulatory arrest. In the context of resuscitation attempts, the term futility can, on the one hand, be defined strictly physiologically, in the sense of the clear impossibility of restoring the cardiac pumping function. The extended definition of the futility of resuscitation attempts, on the other hand, includes an estimate of the nature of survival (duration of survival, neurological outcome) after circulatory arrest. The two definitions share the problem of containing an evaluation of the objective of out-of-hospital resuscitation attempts. In emergency medicine the standard of care remains the start of resuscitation attempts. Physiologically defined futility justifies the decision to withhold resuscitative efforts. In a particular case the refusal by the patient as well as an expected bad prognosis which is inconsistent with the patient's interest could support the emergency physician's decision not to initiate resuscitation. Such an individual decision should not only be guided by medical, but also by ethical considerations and be based on general ethical principles.

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