Can opt-in cardiopulmonary resuscitation be legally and ethically justified?

Dr Susan Hertzberg1

1Prince Of Wales Hospital

The era of modern of cardiopulmonary resuscitation (CPR) began in the late 1950s and despite evolving recommendations to improve outcomes, the rate of successful resuscitation remains disappointingly low. CPR was originally developed to save the lives of people who arrested unexpectedly- “ hearts too young to die”- but it is now the default treatment for any patient in any hospital or aged care facility (ACF) in Australia unless the patient has a “not for resuscitation” (NFR) order. There are many problems with the opt-out option of CPR. They include; assuming rather than obtaining patient consent, patient’s and family’s unrealistic expectation of the likelihood of success, low uptake of the NFR form meaning many patients who will not benefit from CPR still get it, lack of consensus around futility at the end of life, legal uncertainty around NFR orders, reluctance on the part of the medical team to have an emotionally charged conversation and failure to offer patients and their families better alternatives for end of life care. It is time to re-evaluate the way in which CPR is delivered to patients whose “hearts are too old or too frail to live” and it is time to adopt an opt-in CPR model for residents of aged care facilities and hospices. This talk will review the process of CPR and its associated mortality and morbidity. It will address the symbolic function of CPR where it is clearly futile; the concept of the dishonest and ethically questionable ‘slow code.’  The current procedure for opting out of CPR using the NFR order form and the legal uncertainties associated with this form will be reviewed.  I will outline the logistics of opt-in CPR and conclude that it is time to demonstrate clinical leadership in situations where inappropriate use of CPR is prolonging death, not life.


Dr Susan Hertzberg is an Emergency Physician working as senior staff specialist in the Ermergency Department at the Prince of Wales Hospital (POWH) where she is the Co -Director of Emergency Medicine Training. She holds Masters Degrees in both Health Law and Bioethics from the University of Sydney. She is on the Ethics Committee and the Fellowship Examination Committee of the Australasian College for Emergency Medicine. She is a tutor in ethics in the Faculty of Medicine at the University of New South Wales and a conjoint senior lecturer in the POW medical school.

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