Who should make
resus decisions?
Dr Regina Mc Quillan
Palliative Medicine Consultant
Guardian newspaper
Goals of Care
To cure sometimes, to relieve often, to
comfort always
An intervention may
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Cure
Rehabilitate
Prolong life
Stabilize condition
Palliate
Fail
Ethical Behaviour
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‘Good is to be done and evil avoided’
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Act in the patient’s best interests (Medical Council 4.1)
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Primum non nocere
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Beneficence
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Non-maleficence
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Consider which treatment option would provide the best clinical
outcome for the patient (Medical Council 34.6)
Twentieth century
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Antibiotics
Surgery and anaesthetic advances
Cancer treatment
Diabetes management etc, etc
Create an expectation that health can be maintained and
death deferred, but at some point, treatment not helpful
Challenges in treatment
decisions
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Drive to do all to prolong life
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The technological
imperative
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Sanctity of life
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Appropriate recognition of
impossibility of prolonging
life, and preventing death
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Rights and responsibilities
to withhold or withdraw
treatment
Do Not Attempt Resuscitation
Order
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A form of advance directive or advance care
plan
DNAR
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Urgent need to institute treatment
At a time when patient is unable to consent
If there is no DNAR, presumption
in favour of ACPR
Medical Council- End of Life Care
22.2 There is no obligation to start or continue a treatment,
or artificial nutrition or hydration, that is futile or
disproportionately burdensome
22.4 You should take care to communicate effectively and
sensitively with patients and their families so that they
can have a clear understanding of what can and cannot
be achieved
Futility
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Futility is goal specific
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Physiological futility is when the proposed intervention
cannot physiologically achieve the desired effect. Most
objective definition
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Quantitative futility is when the proposed intervention is
highly unlikely to achieve the desired effect.
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Qualitative futility is when the proposed intervention, if
successful, will probably produce such a poor outcome
that it is best not to attempt it
Sokol, DK. BMJ 2009; 338:b2222
Futile treatment as ritual

Rituals are used to make
sense of life events
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CPR may be futile, but
when it fails, clearly defines
for the family and staff the
moment of death
Mohammed and Peter, Nursing Ethics, 2009,16(3)
292-302
Attempted cardiopulmonary
resuscitation
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Less than 2% success rate
Success rate lower with increasing age,
co-morbidities, unwitnessed arrests, out of
hospital
When to make decision?
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Health care transitions
New diagnosis of fatal illness
Deterioration in chronic illness eg
-multiple admissions with eg COPD, CCF
-MND needing RIG or NIV
-nursing home admission
-dementia with feeding problems
-cancer progression
Who makes the decision?
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Patient choice to refuse treatment even if lifeprolonging
If ACPR is not futile, consider patient involvement
If ACPR is futile, should not be offered
If patient requests ACPR which is considered futile,
explore understanding of ACPR; the patient’s wishes
should be respected where possible. Doctors are
not required to give treatment against their wishes.
DHRMF 2010
Who makes the decision?
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No one has the right to make a health care
decision for an adult.
Decision-making is the responsibility of the
doctor in charge, and must be in the best
interests of the patient, in consultation with
the multidisciplinary team and the patient’s
family network
Consultation with the family, sensitive and
clear
Family
Family
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Whose is the family?
Family
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Whose is the family?
Their role is to represent what the patient’s
wish may be
Must consider the patient’s best interest
Team conflict
Team conflict
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If you keep on doing what you are doing, you
will keep on getting what you’ve got
Team conflict
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If you keep on doing what you are doing, you
will keep on getting what you’ve got
Everybody acts in the patient’s interest
Team conflict
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If you keep on doing what you are doing, you
will keep on getting what you’ve got
Everybody acts in the patient’s interest
How to effect change
Communicating the decision
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To the patient, if appropriate
To the family, for information, not decision
In healthcare record
In transfer documentation
Who makes resus decisions?
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The patient can refuse
The patient can’t insist on futile treatment
If there is doubt about the value, the doctor
makes the decision, in the best interests of
the patient, following consultation with the
patient, family and MDT.
Additional reading
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Medical Futility: its Meaning and Ethical Implications.
Schneiderman, Jecker, Jonsen. Annals of Internal Medicine.
1990:112:949-954
Debate: Extraordinary means and the sanctity of life. Journal of
Medical Ethics. 1981: 74-82
Guide to Professional Conduct and Ethics for Registered
Medical Practitioners 2009