- BIOETHICS FORUM ESSAY
Don’t Categorically Refuse CPR to Ebola Patients
Recently it has been argued that cardiopulmonary resuscitation (CPR) should, as a matter of policy, not be offered to persons with Ebola disease. Such a categorical restriction of CPR based solely on a patient’s diagnosis rather than his prognosis would be unique in modern medical practice. Beyond this, the general public’s concerns about Ebola, marked by fear and manifested by the social exclusion of recovered patients and their families, makes it especially important to avoid even unintentional suggestions that Ebola is not like any other life-threatening illness.
While the overall survival rates for persons requiring in-hospital CPR are low, specific patients may benefit from CPR, and categorically restricting use of this procedure could further contribute to the social devaluation of Ebola patients. However, staff who courageously accept the responsibility of caring for them are entitled to every effort we can make to secure their safety from the contagion.
Several commentators have proposed that, while a range of intensive interventions may be appropriate in caring for patients with Ebola, “the line should be drawn at CPR.” Some institutions are said to be considering similar limitations. (See Reuters and the Wall Street Journal.) The arguments of those opposed to offering CPR have rested on several presumptions: the concern that resuscitation would be counterproductive (nonmaleficence), the claim that persons with Ebola who experience cardiorespiratory arrest cannot be saved (futility), that the requirements for adequate personal protective gowning would delay resuscitative efforts unacceptably, and the fear that CPR would expose hospital staff to unacceptably high risks for infection. These notions reflect misconceptions about the clinical disease and do not take into account current approaches to the care of patients with Ebola.
To begin, while Ebola is considered a “viral hemorrhagic disease,” the occurrence of clinically important hemorrhage is so low that the disease has been renamed to de-emphasize the occasional hemorrhagic manifestations. While Ebola is associated with a variety of clotting abnormalities, it has not been characteristic for patients in the current outbreak to have dramatic or life-threatening hemorrhages that could be sources of infection of staff providing care for them. Indeed, most bleeding in Ebola patients has been associated with mucous membrane or gastrointestinal bleeding or occasionally with purpuric eruptions. It is not realistic to worry that CPR would be likely to exacerbate internal hemorrhage which could aggravate a patient’s clinical status, though in a person who has suffered cardiac arrest it is not clear that the risk of further aggravating their condition is a meaningful concept.
Second, it appears that the principle pathophysiologic disorder in Ebola, at least initially, is massive fluid and electrolyte loss, particularly resulting in severe hypokalemia, hypomagnesaemia, and hypocalcemia. It is not surprising that patients are at risk of life-threatening cardiac arrhythmias, a cause of cardiac arrest which is often reversible electrically and with drugs. This cause of cardiac arrest would not necessarily reflect an otherwise futile prognosis, but would be one from which we could expect patients to recover. Such instances requiring cardiac resuscitation would seem to offer no greater risk to staff than other non-invasive medical procedures.
The need for fully protective gowning in order to care for patients with Ebola is clear, and the time to get into such attire, perhaps 10 minutes or more, would be an unacceptable delay to beginning CPR. However, it is current practice to have patient rooms always attended by at least one fully gowned staff member who could initiate pulmonary resuscitation while others were preparing themselves to assist. Such a situation might not unacceptably delay the onset of adequate oxygenation until drugs or electrical resuscitation could be provided.
Concerns for the safety of staff caring for Ebola patients should certainly be carefully considered in evaluating any care plans for this disease. Indeed, the successful care of such patients in the U.S. has been to a large degree a reflection of the very detailed planning carried out around all issues of infection control related to Ebola virus infection. Even such procedures as hemodialysis have been carried out safely in Ebola-infected patients following very carefully designed protocols.
Our experience with Ebola in this country is still extremely limited and our understanding of the natural history of the disease, its potential complications, and their response to therapy must be learned. At this time, it is extremely premature to consider patients with Ebola suffering cardiac arrest to be unsalvageable, when in fact patients both in the U.S. and abroad with severe complications, including multi-organ system failure, gram-negative sepsis, or coma, have recovered.
Our ability to mitigate much of the risk of caring for Ebola patients through proper infection control procedures, and the evidence that this, while a very serious disease, need not be routinely fatal, seem to me to argue strongly that, at this point in our clinical experience, there is no basis for categorically refusing resuscitation to patients with Ebola, a step which would only seem to confirm those people who see this disease as principally something to fear, and persons suffering with it to be in some sense beyond the pale of modern medical care.
Paul J Edelson, MD, is an epidemiologist and infectious disease specialist on the faculty of Columbia University, with a particular interest in the ethical issues of emerging infectious diseases.
Posted by Susan Gilbert at 01/15/2015 10:48:55 AM |