A 30-year-old man collapses in the downtown area of a large city. He is thin and looks chronically ill. A friend is with him and asks people passing by if they know CPR.
When they approach, he tells them that his friend has AIDS and has been battling an infection for the last several months.
People offer to call 911 for paramedics and an ambulance, but nobody wishes to initiate CPR.
The paramedics arrive at the scene in about five minutes. They find that the patient has no vital signs, and they start CPR. His electrocardiogram shows an asystolic rhythm.
(Asystole means the heart has no rhythm at all. It is a very poor prognostic sign, and in the vast majority of cases, patients in this rhythm are clinically dead and cannot be resuscitated.)
The paramedics call their base station hospital and report that the patient is suffering from AIDS and is under the care of Dr. Smith.
Because of the patient’s chronic condition and poor prognosis, they request that endotracheal intubation and intravenous drug administration be postponed until the patient reaches the hospital in about five minutes.
They would like simply to continue basic CPR and transport the patient to the hospital.
They would like to avoid exposure to the patient’s secretions (saliva, etc.) and blood for their own health and safety. (Intravenous injections and endotracheal intubation may expose them to the patient’s blood and secretions.)
What are the obligations of the physicians, paramedics, and citizens in this case?
Commentary
This very interesting case illustrates several important ethical dilemmas relevant to the practice of the emergency medicine professional. Let us approach it by reviewing some of the ethical questions involved.
First, should a health care provider allow information obtained from an interested third party to influence critical therapeutic decisions?
In this case, can the physician assume that this patient really does have AIDS? Or is his “friend” an evil business partner who just poisoned his victim and is now attempting to foil any resuscitation procedures?
In general, one should not allow information from a friend or relative to affect resuscitation decisions even if there is no evidence that criminal motives are involved.
Perhaps his friend is simply “mistaken” and merely “suspects” that the victim has AIDS because he has been looking tired and is homosexual. There can be little justification for health care providers letting such “heresay” information influence critical decisions regarding resuscitation.
If his “friend” is mistaken, or has ulterior motives, we have done the patient a great injustice.
Thus, in this case, if the only information that the paramedics and base station physician have is the friend’s comment, they are obligated to proceed with full resuscitation procedures in the field and the emergency department.
If there is any question of infectious contamination, the paramedics should be advised to minimize direct contact with body fluids through the use of gloves, masks, etc.
What are the obligations of the citizen who may know CPR but, in this case, is afraid to perform it? This is a much more difficult question. Indeed, there is uncertainty as to whether the friend’s information is correct.
However, if he is correct, the bystander may be risking exposure to a fatal viral disease. Typically, bystanders will not have breathing masks, surgical gloves, etc., to protect themselves.
Mouth-to-mouth breathing during CPR may involve exposure of the bystander to the patient’s saliva.
Although no patient with AIDS has been shown to have acquired it through saliva exposure, the virus is reported to be present in the AIDS patient’s saliva and thus represents a potential danger to the bystander.
Furthermore, a distinction must be made between the bystander and a professional health care provider. The health care professional has chosen his career with full knowledge that it may, at times, entail risks to infectious diseases.
The health care provider is given a respected place in the community; frequently his education and, sometimes, his employment are subsidized by public funds.
He truly has an obligation to treat all patients in need of his services despite some personal risk, though he may not be obligated to incur high risks. The bystander who happens to have taken a CPR course does not have the same strong obligation.
It should remain a personal decision for the bystander, who must balance personal risk and potential gain for another person.
Unfortunately, both are unknown in this case. If the bystander chooses not to perform CPR because of the unknown risk of exposure, he does, however, have an obligation to do whatever else he can to help the patient.
This may involve calling “911” for emergency medical professionals, clearing the area, and directing paramedics to the victim.
What if we can confirm with reasonable certainty that the patient does, indeed, have AIDS? Perhaps he is wearing a Medic Alert bracelet, or his physician, Dr. Smith, is immediately available to confirm the diagnosis in this patient.
Does this change the obligations and responsibilities of the health care professionals to provide resuscitation for this patient? The system of health care in the United States generally tries to respect patient autonomy.
The patient with a serious terminal illness should decide for himself whether aggressive resuscitation attempts should be instituted or not.
Ideally, this would involve frank discussion with the patient, his family, and his physician. Unfortunately, these discussions are often not held while the patient is well enough to make this decision.
Even if such conversations are held, situations in the emergency department or prehospital care setting are such that the decision might not be known with certainty.
Once again we may be faced with the question: “Do you believe a friend who says the patient didn’t want to be resuscitated?” In the emergency department and in the prehospital care setting, we must always err on the side of treatment.
If a decision “not to resuscitate” has not clearly been reached by the patient in consultation with his physician and family, we are obligated to institute full resuscitation procedures.
This would certainly be the reasonable conclusion, based on respect for patient autonomy, under conditions in which resource scarcity is not a problem.
However, let us explore an alternative point of view. In general, patients in cardiac arrest who present with an asystolic rhythm have a very poor prognosis for resuscitation.
In some studies in the medical literature, survival rates approach zero. In some emergency medical systems, paramedics under the direction of their base station physicians may terminate resuscitation procedures and pronounce patients with unresponsive asystolic rhythms dead.
One can speculate that this patient, although younger than most cardiac arrest victims, has an even poorer prognosis for survival.
The presence of a significant underlying disease decreases the chances of his successful resuscitation. This is probably because his underlying disease is so severe and overwhelming that it has caused his heart to stop beating.
For example, his lung infection may have become so severe that it prevented him from getting oxygen into his blood and heart, causing his heart to stop beating.
It would be very difficult to resuscitate this patient without reversing the infection in his lungs that is not allowing him to get oxygen into his heart.
A poor prognosis alone, however, is not the only factor involved in this viewpoint. What are the costs to society of this attempted resuscitation? The provision of medical care is not a limitless resource.
The extent of care we provide is often limited by political and economic decisions. Over the past decade, there has been a strong emphasis on prepaid health maintenance groups where incentives will be to limit the expenditures for patients with a poor prognosis.
The ethical questions which this emphasis on cost containment raises are beyond the scope of this case commentary. I bring this up merely to illustrate the fact that cost containment is a concept that will have major impact on the practice of medicine in the United States.
We have only limited resources that our society is willing to spend for medical care. Thus, decisions on the appropriate use of these resources will become increasingly important and may change the basic tenants of medical care as we know it.
In fact, reimbursement systems that place new limits on patient choice are slowly becoming more prevalent in the United States today.
For example, if you belong to a prepaid health plan, it is the doctor, not you (the patient), who determines if you can be seen at night in an emergency department and at which emergency department you should be seen.
If you are a patient with kidney stones, it is the doctor, not you, who determines whether you will be seen by a urologist or will be treated by a general practitioner.
One can argue that to resuscitate our patient with a terminal disease is a needless waste of medical resources, regardless of whether the patient wants full resuscitation procedures instituted.
Resuscitating the patient is unlikely, resuscitating him and having him return to a productive life is even more unlikely. In this view, the patient does not have a broad enough view of the system, including its scarcity of resources, to make an appropriate decision.
This argument can be used not only for patients with AIDS but also for all patients with terminal illnesses such as metastatic cancers.
Perhaps “do not resuscitate” orders should be placed on all patients with progressive terminal diseases even without patient consultation. Should it be a decision based solely on medical prognosis and resource allocation?
In the case of our AIDS victim in cardiac arrest, another factor enters into our consideration — the health and safety of health care personnel.
As discussed above, health care personnel, by virtue of their training and choosing this profession, have a special obligation to help their patients, even if there is some personal risk.
Of course, if the personal risk is very high and the likelihood for patient benefit very low, one must reconsider this obligation.
For example, patients with rabies almost universally die soon after they develop neurologic symptoms. If such a patient suffers a cardiac arrest, should health care workers be obligated to perform mouth-to-mouth resuscitation for CPR?
Such contact would expose the worker to the rabies virus in the patient’s saliva, putting him or her at considerable risk of developing a universally fatal disease.
Furthermore, the likelihood of successfully resuscitating this patient is small; the likelihood that the patient will ever leave the hospital alive is virtually nil (cures in unusual cases rarely occur). Thus a cogent argument could be made not to do mouth-to-mouth breathing or even attempt to resuscitate the rabies patient.
For the AIDS victim in this case, the scientific data are less clear. What is the risk of exposure to the patient’s saliva? What is the risk of exposure to the patient’s blood on a gloved hand?
What is the likelihood that a patient with an asystolic arrest will ever leave the hospital? The answers to these questions are not definitively known at this time.
More information from the scientists may be available in a few years. The prevailing opinion at the present time is that when some simple precautions are taken, such as the wearing of gloves, the risk to the health care worker of starting an intravenous line or placing an endotracheal (breathing) tube in the patient’s mouth is slight.
While there is a lot of paranoia regarding AIDS, and while it is a very serious disease, there is not enough evidence of risk to health care workers to justify treating these patients differently than any other terminally ill patient, such as a cancer victim.
A final point needs to be made regarding the approach to health care which limits optimal patient care on grounds of scarcity of resources.
While this view has merit and may eventually predominate in our health care system as it does in other countries, it is not presently recognized as the standard of care by either our society or our legal system.
Patient autonomy and a commitment to doing the best we can for the individual patient has a strong tradition and is very highly regarded in our society.
If as a society we believe that, indeed, health resources and expenditures need to be limited, our legislators, jurists, policymakers, and health care providers need to discuss openly what these limitations are to be and how allocation decisions are to be made.
Except in actual triage situations, it would be folly for an individual health care worker to make a critical decision based on an “allocation of scarce resources” argument when the rest of the health care system and society operates on a different premise.
Where does it leave our AIDS patients in a cardiac arrest?
In our present health care system and with our present knowledge of the limited risks for health care workers, it is the obligation of the physician and the paramedics to attempt to resuscitate the patient to the full extent of their capabilities.
In this case, the base station physician should firmly order the paramedic to put on gloves and intubate the patient (place the breathing tube through his mouth into the trachea), start an intravenous line, and administer appropriate drug treatment.
