Is it ethically justifiable for physicians to hold back cardiopulmonary resuscitation (CPR) unilaterally?

With intensive care units overflowing with patients due to the COVID-19 pandemic, front-line physicians are disputing whether it would be appropriate to withhold providing CPR to COVID-19 patients.

Recently, the American Medical Association (AMA) issued a comprehensive ethics guideline on Do Not Resuscitate (DNR) orders during a public health crisis, citing opinions from the AMA Code of Medical Ethics. According to the Code of Medical Ethics Opinion 5.4, “Orders Not to Attempt Resuscitation (DNAR),” patients and surrogates are given the authority to receive or request orders not to resuscitate. And physicians are required to respect their decisions to refuse care. “But there have been conversations during the COVID-19 pandemic about making it a mandate, so it’s not a decision between patient and physician,” stated Elliott Crigger, Ph.D., director of ethics policy at the AMA.

사진 출처: https://www.myamericannurse.com/improving-in-hospital-cardiac-arrest-survival-with-innovative-cpr-training/

Opinion 5.5 “Medically Ineffective Interventions” permits physicians to withhold CPR without explicit consent from the patient or surrogate when the treatment does not reveal the potential to offer clinical benefit. And reports have indicated that for COVID-19 patients on ventilators, CPR is very unlikely to be successful. Heightened transmission risk to physicians during resuscitation must also be considered as intense activity and contact ensue in the CPR process. Opinion 8.3 “Physicians’ Responsibilities in Disaster Response & Preparedness” places another responsibility on physicians to assess the perils of giving medical care to individual patients versus the need to provide care in the future.

This all comes down to utilitarianism: producing the greatest good for the greatest number. In a public health crisis such as the COVID-19 pandemic, the ultimate objective is to maximize benefit and minimize harm for the greatest number of patients. However, the individual lives of COVID-19 patients must not be overlooked altogether. Therefore, opinions on DNR orders, presented by both physicians and patients, must be heard and contemplated to prevent further ethical concerns in the future.

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