(378) Have We Done Enough? A Systematic Review of Ethics Exploring CPR Termination in US Hospitals

Introduction: Emergency providers face an almost impossible decision when running medical and traumatic codes. Beyond medical considerations of futility lie a complex web of decision-making points. We hope to systematically evaluate the ethics literature to provide more guidance on what factors are ethically relevant when determining futility during an active code.

Methods: We performed a qualitative systematic review of reasons given for when to terminate a code in United States hospitals. A librarian searched MEDLINE, Embase, CINAHL, and Web of Science databases for terms including but not limited to CPR, ACLS, PALS, termination, futility, and ethics. The search was originally conducted on 05/16/2024. After duplicate removal, 12,863 articles underwent dual, independent screening. We identified 350 studies meeting inclusion criteria, which were subsequently reviewed for argument quality and analyzed for ethical position, reasons given, and concepts.

Results: The most common ethically relevant reasons given for termination include time down, asystole for >20min, circumstances of arrest, and presence of reversible factors – collectively coded as medical factors. Several domains were identified as potentially ethically irrelevant including age, race, sex, and comorbidities/non-cardiac disability status. We identified several professional guidelines used to help guide decision making when terminating a code including the most commonly used Universal Termination of Resuscitation rule.

Conclusions: The decision to terminate a code is never an easy one, but one that every emergency and critical care physician will make in daily practice. Throughout the past several decades professional societies and hospitals have attempted to standardize in-hospital CPR. However, variation in individual practice still remains an ongoing challenge. While physiologic data affecting likelihood of success is universally accepted, factors such as age, race, comorbidities, disability status and sex are controversial. This review found that physicians may be using ethically irrelevant data to make decisions regarding termination. We advocate for universal ethical guidelines to help ensure frontline clinicians make resuscitation decisions without bias and with the best chance for a medically beneficial outcome.