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A 25-year-old male is brought to the emergency department by medics at midnight on Saturday night after being assaulted outside a downtown bar. The medics report that he was hit on the head and unconscious for a few minutes. When they arrived at the scene, the patient was confused but talking. He has a 4-inch laceration in his left parietal scalp and alcohol on his breath. When the patient arrives in the emergency department, he is slurring his speech and reports drinking several beers at the bar before being assaulted. He refuses any diagnostic tests or therapeutic interventions. He does not let the nurse start an intravenous line or draw blood, nor let the physician examine his laceration or do an adequate neurological examination. He demands to leave. He says he has been assaulted before and will be OK. He becomes increasing abusive to the staff and repeats his demands to leave.
The paramedics are called to a skilled nursing facility for an 80-year-old woman who is in cardiac arrest. The patient was last seen four hours previously by a healthcare aide and later found in her room unresponsive. When the medics arrive, the patient is unresponsive with no pulse or blood pressure. They call their base station asking to declare the patient dead. They say that it is futile to resuscitate elderly patients in nursing homs because such patients never survive. In addition, since she has been down a long time she will have severe neurological dysfunction. The patient has no advance directive.[…]
Peter Baskett, Stanton St Quentin, Wiltshire, UK, Department of Emergency Medicine, University of Arizona, Tucson, AZ, USA, Oslo, Norway,
Arthur B. Sanders, Stanton St Quentin, Wiltshire, UK, Department of Emergency Medicine, University of Arizona, Tucson, AZ, USA, Oslo, Norway,
Petter Steen, Stanton St Quentin, Wiltshire, UK, Department of Emergency Medicine, University of Arizona, Tucson, AZ, USA, Oslo, Norway
Successful resuscitation attempts have brought extended, useful, and precious life to many, and happiness and relief to their relatives and loved ones. And yet there are occasions when resuscitation attempts have merely prolonged suffering and the process of dying. In a few cases, resuscitation has resulted in the ultimate tragedy – the patient in a persistent vegetative state. It is to be remembered that resuscitation attempts are unsuccessful in 70%–95% of cases and death ultimately is inevitable. All would wish to die with dignity.
A number of ethical decisions are required to ensure that the decisions to attempt or withhold resuscitation are appropriate and the patients and their loved ones are treated with dignity. These decisions may be influenced by individual, international, and local cultural, legal, traditional, religious, social and economic factors. Sometimes the decisions can be made in advance, but often they have to be made in a matter of seconds at the time of the emergency. Therefore, it is important that healthcare providers understand the principles involved before they are put in a situation where a resuscitation decision must be made.
This chapter will deal with the following ethical aspects and decisions:
Advance directives, sometimes known as Living Wills
When not to start resuscitation attempts
When to stop resuscitation attempts
Decision making by non-physicians
When to withdraw treatment in those in a persistent vegetative state following resuscitation
The percentage of elder persons throughout the developed world is rapidly increasing. In the USA, for example, the percentage of the population 65 years and older has increased from 4% in 1900 to 13% in 1990 and is projected to be 22% by 2030. The fastest growing segment of the elderly population is the oldest persons who are 85 years or older and made up about 1% of the population in 1990 but will increase to more than 5% over the next 30 years.
Similarly in developed countries worldwide (including Japan, Australia, New Zealand, and countries in Europe and North America) the elderly segment of the population is increasing significantly. The highest proportion of elderly people in the world is in Sweden, with 18% of the population 65 years or older. This demographic change with increasing numbers of elder persons in the population is expected to continue over the next 30 to 50 years. By the year 2025, 5%–9% of the population in the developed nations will be 80 years or older.
This graying of the population in the developed world is largely due to several demographic factors. This includes a decline in the mortality rate especially from cardiovascular diseases and decreased fertility rates in much of the developed world. The post-World War II baby boom generation in the USA consists of 75 million persons born between 1946 and 1964. These people will be entering the geriatric population over the next 20 years.
This increased population of elder persons will have a major impact on the delivery of healthcare.
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