Responding to Ebola: Questions about Resuscitation
Medicine
Joseph J. Fins, 10/10/2014

Responding to Ebola: Questions about Resuscitation

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While details of the deaths of patients in Dallas and Madrid from Ebola are not public, their passing prompts questions about resuscitation in individuals infected with the virus. To date, this question has not been raised in clinical ethics. We must now consider whether unilateral do-not-resuscitate orders are justified in this discrete clinical circumstance.

To start, we need to ask whether resuscitation is safe. It may not be so in those Ebola patients who have uncontrolled bleeding. In that setting chest compressions could make matters worse and accelerate exsanguination. This could make cardiopulmonary resuscitation (CPR) contraindicated in the minority of patients who have bleeding.

Another major challenge is the feasibility of CPR as it relates to staffing and timing. If a patient arrests, a team would have to arrive and suit up in protective gear before resuscitation could safely begin. (No one should expect that physicians, nurses, and respiratory therapists should just rush in, as is the norm, for "conventional" codes. If society harbored such expectation, we would encounter work force issues and no one would volunteer to provide care.)

Beyond the question of whether CPR is indicated is one of logistics. Arriving at the room of a patient in cardiac arrest and suiting up could lead to a delay of several minutes, raising the risk of hypoxic brain injury or anoxia for patients who are not yet intubated. This raises questions about the futility and utility of resuscitative intervention itself, in addition to the intrinsic lethality of the disease by the time there is hemodynamic collapse.

To provide timely care a hospital would need to staff 24/7 suited teams who would be immediately available to a patient in cardiac arrest. At least two teams would need to be staffed because clinicians can only wear protective gear for a limited period of time and rotation is necessary for staff once they are in the patient's room. So one team would be needed to provide an emergent response and another one or two to provide continuous care – as one team departs to be decontaminated, others would need to go in. 

From a clinical, public health, and disease containment perspective, codes are dangerous. Emergent line placement and intubation can expose staff to blood and secretions in an often chaotic and uncontrolled setting. Imagine a code in a suburban emergency room that was not expecting the arrival of a patient with Ebola. 

There is a grave health threat for well-intentioned and heroic staff who might rush in without protective gear, or more likely improperly attired, as the case of the Spanish nurse suggests. And for the local ecosystem there is the risk of expanding the reach of the epidemic as staff contract the illness. 

Given this, it seems that we should think carefully about the outright utility and proportionality of cardiopulmonary resuscitation. Bleeding patients may be harmed by CPR. Others yet to be intubated could sustain brain injury because of time delays necessitated by the need to arrive and don protective gear. For most, if not all, it will be a futile act because of the lethality of their advanced state of illness, the multisystem organ failure which precipitated cardiac arrest in the first place. CPR in these settings also needs to be weighed against the public health risks associated with its provision and the real risk of contagion and spread with emergent resuscitation. 

Patients with Ebola should receive all medical measures and experimental interventions including ICU care. This includes massive fluid replacement and dialysis which has been reportedly employed. But the line should be drawn at CPR. Unilateral do-not-resuscitate orders would seem justifiable under these circumstances, if surrogates do not otherwise agree to a DNR order.

The utility of CPR should be discussed with patients and surrogates as with any other patient. Patients and families should be assured of all available intensive care and comfort measures but the presumption of resuscitation should be reconsidered in acute care settings. Hospitals should develop policies that reflect their views on resuscitation before a patient arrives. State departments of health and federal officials should review laws – and policies – on presumed resuscitation, as they relate to Ebola, clinical practice and the public health. These policies should emphasize proportionate, compassionate and realistic goals of care and must also protect staff from post-hoc reassessment of their actions.

I am surprised to make this argument. Over the past two decades since I began to write in medical ethics I have been a proponent of patient autonomy and surrogate choice. Early in the AIDS epidemic, when I was a resident caring for patients with HIV, I rejected similar arguments. I willingly participated in numerous resuscitations and thought them appropriate when consistent with patient and family wishes. Neither then nor now was I a proponent of unilateral DNR orders in HIV/AIDS.

Given this I am troubled to be on the other side of the argument, but I believe that there is a difference between resuscitation in patients infected with the HIV versus the Ebola virus. Resuscitation of patients with HIV, even in the pre-HAART (highly active antiretroviral therapy) era had therapeutic utility. Conditions like Pneumocystis carinii (now called Pneumocystis jiroveci) which caused pneumonia and respiratory failure, sometimes leading to cardiac arrest could be treated with available antibiotics. Resuscitation helped our patients fight another day and perhaps even survive to eventually benefit from life-saving therapeutics like HAART, which has made HIV/AIDS almost a chronic health condition.

The same cannot be said for Ebola. There is no available therapy for Ebola, all the more so for patients in extremis. This makes resuscitation an act of futility and a symbolic homage to a mistaken notion of patient autonomy.

And this leads me to my final point. The foregoing debate about resuscitation is entirely misplaced in face of the global epidemic. It is a footnote, to the larger text of a neglected disease which has only gained attention because it has finally arrived in the “developed world.” Perhaps if the global community had attended to this crisis sooner there might be proven and widely available treatments which would make my argument moot. I wish it were so.

Acknowledgements: I would like to acknowledge fruitful discussions with my colleagues Drs. David Berlin, Ellen Meltzer and Natalia Ivascu as well as Cathy Acres, R.N.

Joseph J. Fins, M.D., M.A.C.P., is The E. William Davis, Jr., M.D. Professor of Medical Ethics, chief of the division of Medical Ethics, professor of medicine, professor of health care policy and research, and professor of medicine in psychiatry at Weill Medical College of Cornell University. He is also Director of Medical Ethics at New York Presbyterian Hospital Weill Cornell Medical Center. He is a Hastings Center board member and fellow and is the author of Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness, which will be published by Cambridge University Press in 2015.

 

Posted by Susan Gilbert at 10/10/2014 10:59:52 AM | 


As a largely-retired neurologist formerly involved in issues of prognosis from hypoxic brain injury, I agree fully with the opinion expressed by Dr. Fins. In view of the hysteria we have recently seen in Dallas and Ohio, however, I am concerned that if even a few more cases of Ebola enter the US, EMTs might unilaterally decide against administering CPR in the field once the influenza season arrives. There will be no way for them to know if a patient who arrests with a fever in the field does or does not have Ebola. This possibility needs discussion as the flu season approaches.
Posted by: delevy@verrizon.net ( Email ) at 10/21/2014 11:43 AM


I find the blanket do-not-resuscitate proposal too broad a brush. I agree that, when someone is exsanguinating or in multi-organ system failure, CPR that includes chest compressions is so unlikely to change the outcome that the accompanying risk to healthcare professionals cannot be justified. There are many reasons for and types of "codes," however. For instance, cardioversion (shocking) poses little risk to clinicians and provides some possibility of benefit (in some patients); similarly, intubation in a patient who is NOT exsanguinating could provide meaningful benefit which could justify risk to properly protected clinicians.

I find the assumption that the time required for proper donning of protective gear would lead to brain injury ignores the variety of causes and types of "codes" as well as the uncertainty of predictions about such outcomes. I certainly agree that health care professionals should be expected to - required to - don protective gear, and be trained in how to do so correctly. But I don't think the resulting delay should _always_ lead to an assumption of the futility of CPR.
-Susan Goold
Posted by: sgoold@umich.edu ( Email | Visit ) at 10/22/2014 3:51 PM


I respectfully disagree with Joseph Fins’ stance. Here is my reasoning:

If CPR can be performed without excess risk to healthcare workers, and if it is not futile in all cases of patients with Ebola who suffer cardiac arrest, then it is unethical to make an institutional policy that imposes a DNR status on patients with Ebola.

1. CPR can be performed without excess risk to healthcare workers.

Consider a patient who is being attended by a nurse and who suffers cardiac arrest. The nurse caring for him is wearing appropriate protective equipment at the time. He or she can initiate CPR without additional risk because delivering chest compressions does not present a significant additional risk in this scenario. Chest compressions can be continued while the code team suits up in appropriate gear.

As long as appropriate equipment is worn, there is not reason to believe that providing CPR and ACLS carry a special risk not found in other medical interventions that are performed on Ebola patients (placing iv’s, cleaning patients who have had bloody bowel movements, intubating a patient in respiratory distress).

2. CPR is not futile in all cases of patients with Ebola who suffer cardiac arrest

Consider a patient who presents hypotensive and with severe anemia due to hemorrhage from Ebola. This advanced stage of Ebola carries a high mortality. Yet, patients with similarly severe illnesses are routinely offered resuscitation and CPR. Think of sepsis, trauma, multiorgan failure in acute AML, severe respiratory failure in influenza, and any number of other conditions that carry a high mortality but also the prospect of full recovery for the minority that survive the acute illness.

Because Ebola is not universally fatal, and because survivors of the acute illness have an excellent chance of full recovery, there is no inherent futility to treating patients with Ebola. There is no reason this argument should not extend to CPR.

3. Institutional policies to impose a DNR status on Ebola patients are unethical

Because of the arguments above, it is unreasonable to withhold CPR from all patients with Ebola. It is easy to imagine a case with a reasonable chance of recovery whose circumstances at the time of arrest permit a coordinated and safe effort at CPR and ACLS. Thus a blanket institutional or even national policy to impose a “DNR status” on patients with Ebola is unethical.

I won’t even pursue the argument that patients undergoing CPR may be harmed by the additional trauma / hemorrhage resulting from CPR. This argument applies to most everyone undergoing CPR, some more (for example, a 20 year old woman with severe thrombocytopenia due to AML, or an 80-year old woman with osteoporosis), and others less. We have left the decision to pursue or forgo CPR for individuals to those individuals, with advice and information offered, and have not attempted to institute blanket policies on their behalf.
-Friederike Keating, UVM
Posted by: fvzm@yahoo.com ( Email ) at 10/23/2014 7:18 AM


Thank you for your thoughtful and provocative article.

While I agree we need to protect healthcare workers, and avoid medically non-beneficial care, it is too soon to conclude CPR is futile for patients with Ebola.

Please see my rebuttal to this article at Health Affairs blog:

http://healthaffairs.org/blog/2014/12/11/should-doctors-deny-ebola-patients-cpr/

Tim Lahey, MD MMSc
Chair, Clinical Ethics Committee
Associate Professor
Infectious Diseases & International Health
Dartmouth-Hitchcock Medical Center
Dartmouth's Geisel School of Medicine
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