Elsevier

Resuscitation

Volume 100, March 2016, Pages 11-17
Resuscitation

Clinical paper
A survey of key opinion leaders on ethical resuscitation practices in 31 European Countries

https://doi.org/10.1016/j.resuscitation.2015.12.010Get rights and content

Abstract

Background

Europe is a patchwork of 47 countries with legal, cultural, religious, and economic differences. A prior study suggested variation in ethical resuscitation/end-of-life practices across Europe. This study aimed to determine whether this variation has evolved, and whether the application of ethical practices is associated with emergency care organisation.

Methods

A questionnaire covering four domains of resuscitation ethics was developed based on consensus: (A) Approaches to end-of-life care and family presence during cardiopulmonary resuscitation; (B) Determinants of access to best resuscitation and post-resuscitation care; (C) Diagnosis of death and organ donation (D) Emergency care organisation. The questionnaire was sent to representatives of 32 countries. Responses to 4-choice or 2-choice questions pertained to local legislation and common practice. Positive responses were graded by 1 and negative responses by 0; grades were reconfirmed/corrected by respondents from 31/32 countries (97%). For each resuscitation/end-of-life practice a subcomponent score was calculated by grades’ summation. Subcomponent scores’ summation resulted in domain total scores.

Results

Data from 31 countries were analysed. Domains A, B, and D total scores exhibited substantial variation (respective total score ranges, 1–41, 0–19 and 9–32), suggesting variable interpretation and application of bioethical principles, and particularly of autonomy. Linear regression revealed a significant association between domain A and D total scores (adjusted r2 = 0.42, P < 0.001).

Conclusions

According to key experts, ethical practices and emergency care still vary across Europe. There is need for harmonised legislation, and improved, education-based interpretation/application of bioethical principles. Better application of ethical practices may be associated with improved emergency care organisation.

Introduction

Cardiac arrest is an unexpected but potentially reversible event and should be distinguished from the expected cessation of cardiorespiratory function as part of natural dying. Survival to hospital discharge following emergency medical service-treated out-of-hospital cardiac arrest is 8–10%.1 This very low survival rate raises ethical considerations. Equally, significant ethical dilemmas have arisen from the rapid evolution of resuscitation science.2 Indeed, as advanced and/or potentially beneficial interventions become widely available and applicable and patient outcomes are improving,1 defining which patients might benefit from new treatments becomes increasingly important.

Healthcare bio-ethics has evolved as bioethicists endeavoured to accommodate dominant cultural and societal trends.3 However, Europe is a patchwork of 47 countries with legal, cultural, religious, and economic differences. These factors affect how European societies interpret and apply ethical principles in resuscitation and end-of-life care. A previous European survey revealed variation in withholding or withdrawing cardiopulmonary resuscitation (CPR), euthanasia, family presence during resuscitation, death diagnosis by non-physicians, teaching on the recently dead, and communicating a failed resuscitation attempt.2

We sought to determine whether the variation in the practice of resuscitation ethics across Europe has evolved. Furthermore, as emergency care design and organisation also probably varies across Europe, we hypothesised that the level of organisation of emergency care might be associated with the level of application of ethical practices.

Section snippets

Methods

Between February and March 2015 an on-line questionnaire was sent to 40 National Resuscitation Council (NRC) Representatives and/or acknowledged opinion leaders in emergency care from all 32 European countries, where the European Resuscitation Council (ERC) has organised activity [see electronic supplementary material (ESM)]. Questionnaire development was based on co-author consensus, and the principles of autonomy, beneficence, non-maleficence, justice, dignity and honesty.4 Co-authors

Results

Responses were originally received from 32/32 countries (100%) and revised Excel datafiles were returned by respondents from 31/32 countries (97%). Only revised data from these 31 countries were included in the final analysis. Respondents provided 73 (99%) of the 74 originally missing data-points. One respondent concluded that he could not answer 6 Domain C questions secondary to regional/local variation in clinical guidelines of healthcare services and/or absence of a specific legal framework.

Discussion

According to national key experts, there is still significant variation in the interpretation of ethical principles across Europe. This is consistent with a previous survey in 2004.2 In the 2004 survey, ethical issues referring to euthanasia, withholding/withdrawing of CPR, family presence during CPR, death diagnosis, CPR training on the recently dead, and breaking bad news in 20 European countries were explored.2 In the current survey, we highlighted differences in a more organised fashion by

Conclusions

Despite progress in the practices of advance directives and DNAR, our key expert perception-based results are suggestive of persisting substantial variation, primarily in ethical practices and emergency care organisation/access across Europe. This implies a need for harmonisation of national legislations and education-based interpretation and overall improved application of the principles of bioethics, in the presence of a rapidly evolving resuscitation science and technology. Our results also

Contributors

Contributors to the Survey on Ethical Practices: Andres J, Baubin M, Caballero A, Cassan P, Cebula G, Certug A, Cimpoesu D, Denereaz S, Dioszeghy C, Fiser Z, Georgiou M, Gomez E, Gradisel P, Gräsner JT, Greif R, Havic H, Hoppu S, Hunyadi S, Ioannides M, Janusz A, Joslin J, Kiss D, Köppl J, Krawczyk P, Lexow K, Lippert F, Mentzelopoulos S, Mols P, Mpotos N, Mraz P, Nedelkovska V, Oddsson H, Pitcher D, Raffay V, Stammet P, Semeraro F, Truhlar A, Van Schuppen H, Vlahovic D, Wagner A

Author contributions

Study conception and design, critical revision of the manuscript for important intellectual content, and final text approval and assumption of responsibility for the integrity and accuracy of the presented work: All Authors. Data collection: LB and VR. Data analysis: SDM and LB. Data interpretation: SDM, TX, and LB. Drafting of the manuscript: SDM, TX, and LB.

Funding

This study was not funded by any source.

Conflict of interest statement

The authors have no conflict of interest to declare.

Acknowledgements

The authors thank Hilary Phelan and the Office of the European Resuscitation Council for the professional help in the design of the on-line questionnaire, of the dedicated database and for collecting the data.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.12.010.

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