An Ethic of CPR as Surgical Procedure

Abstract: There is accumulating evidence that ECPR, the use of ECMO for cardiac arrest in appropriate patients, yields outcomes equivalent or perhaps superior to conventional CPR. The rise of this new treatment creates an opening to reconsider the default status in medicine to provide CPR on request. This near “right” to CPR has been codified in hospital policies and in the laws of some states. Recognizing the incongruity of this approach with the way physicians approach other therapies, ethicists have proposed considering CPR as a potential “futile” treatment or recommended a communication strategy of “informed non-dissent.” However, “futility” arguably creates too high a threshold for declining to offer CPR, and “informed non-dissent” creates confusion about what to do when patients or surrogates in fact dissent. In this presentation, I propose to consider CPR a surgical procedure, similar to those that general surgeons routinely determine whether or not to offer based on their assessments of benefits, burdens, and risks. This shift would apply to CPR the “surgical gestalt” model, which focuses on the necessity of making these judgments about what procedures to offer, rather than the current model deriving from internal medicine in which potential treatments are offered to the patient or surrogate, who makes the decision. It would also align CPR with decision-making about ECMO, which like CPR involves direct manipulation of the body and may soon supersede CPR in effectiveness. In short, the time has come to reconsider the special status of CPR in contemporary medical practice.