Clinical paperA survey of key opinion leaders on ethical resuscitation practices in 31 European Countries☆
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.