Ethical considerations behind the limitation of cardiopulmonary resuscitation in Hungary--the role of education and training.

INTRODUCTION: Although the long term success of cardiopulmonary resuscitation (CPR) is still less than hoped for, its value cannot be questioned when carried out appropriately in selected cases. Resuscitation frequently brings only short-term success, and several patients suffer severe consequences also causing an economic, medical and ethical burden to society. The issue of limitation of resuscitation, including Do Not Attempt Resuscitation (DNAR) and the termination of resuscitation has been surveyed in many European countries using a structured questionnaire. In Hungary no such comprehensive study has been conducted yet. The goal of this investigation was to recognise the ethical factors limiting resuscitation in Hungary.

METHODS: We contacted 72 doctors personally during 2003, who were working actively at an intensive care unit (ICU) and asked them to answer a structured questionnaire in strict anonymity. We investigated the role of different ethical issues in beginning and suspending resuscitation efforts in conjunction with medical experience, sex, ideology, and education using a five point visual analogue scale. The answers given were categorised to autonomy, futility, obtainable quality of life, resource utilization, and to "another" category detailed later on. The questionnaire and the plan of this investigation was approved by the Semmelweis Medical University's Ethical Committee (SE-TUKEB 109/2003).

RESULTS: The decision not to attempt resuscitation was mostly dictated by the opinion of the head of department and the doctor in charge of the patient (3.53 +/- 1.30), and after this the presumed obtainable quality of life (3.13 +/- 1.40), objective futility (3.11 +/- 0.94), and patient autonomy (2.02 +/- 1.63). The other objective (0.57 +/- 1.59), and subjective (1.04 +/- 1.21) factors, as well as resource utilization (0.29 +/- 0.66) played a less important role. The decision to terminate resuscitation efforts was mostly dictated by the objective futility criteria (3.39 +/- 0.88), obtainable quality of life (3.31 +/- 1.50), subjective futility (3.19 +/- 1.47), and autonomy (1.57 +/- 1.67) to a smaller extent. Among the doctors who participated in an appropriate-an internationally accredited (ERC/RC(UK)/AHA)-Advanced Life Support (ALS) training-the frequency of the appearance of the principle of modern bioethics-such as autonomy-was significantly higher and the same tendency could be observed in those who completed their studies at the medical university in the last 5 years.

CONCLUSIONS: The results underline the original presumption that the Hungarian resuscitation practice is at first influenced by professional (or "thought to be professional") standpoints. The quality of life, and patient autonomy plays an important role in the decision making about limitation of resuscitation efforts. Current CPR education emphasizes the importance of ethical considerations, and this could be observed clearly in the answers.