Preventing harm in resuscitation medicine

Abstract

Most often when we proceed to resuscitate the severely unwell and injured various factors conspire against a fully informed consent and therefore we gain permission to proceed on the basis of presumed or implied consent, and this consent is based on the belief that the resuscitation is likely to procure more benefit than harm. If the balance of benefit and harm is unfavourable then to proceed to resuscitate is inappropriate as consent cannot be presumed nor implied. The concept of benefit has been aired in the literature and many have argued the threshold where benefit becomes futility. However, the harm of resuscitation has had scant attention and I have discussed this using Jennett's headings of unnecessary, unsuccessful, unkind, unwise and unwanted. Both benefit and harm in resuscitation are difficult to quantify but even so an appreciation of their balance should guide the resuscitators, the family and the patient in their decision to proceed. Often, and appropriately, a decision to proceed will be made on the basis of a perceived marginal benefit over harm balance made more appealing by an alternative of certain death if resuscitation is not undertaken. This is appropriate if the perceived benefits and harms are made explicit and are appreciated by all concerned so that decisions are not made on the basis of ill-informed expectations. However, the balance is dynamic with a clearer view of the likely benefits and harms emerging as the patient responds or doesn't respond to resuscitation endeavours. If the treatment does not procure the hoped for benefits then all concerned would be disappointed but should not be surprised and should be willing to minimise the ongoing harms of resuscitation by withdrawing treatment as the balance becomes unfavourable. Hershaw suggests; "if doctors can not stop treatment once started they will be afraid to start treatment on patients who have a limited chance of success but who might benefit". By employing medical substituted judgement the resuscitators should recognise when the balance of benefit and harm becomes unfavourable and at this point the resuscitators have a moral obligation to withdraw resuscitation as they can no longer presume the patient's consent. By appreciation of the benefits and harms of resuscitation and by the use of medical substituted judgement to view these from the patient's perspective and by a commitment to withhold or withdraw resuscitation when we can not presume the patient's consent, then we will minimise the harms in resuscitation medicine.