What is the most appropriate course of action for an emergency department physician when a 90-year-old man with terminal cancer and no advance directive (living will) is in cardiac arrest and receiving cardiopulmonary resuscitation (CPR)?

Management of Cardiac Arrest in a 90-Year-Old Patient with Terminal Cancer

The most appropriate course of action for the emergency department physician is to consult with the patient's family or proxy to confirm the patient's care preferences.

Initial Assessment and Ethical Framework

When managing a 90-year-old patient with terminal cancer in cardiac arrest, the physician must balance several ethical considerations:

1. Respect for patient autonomy - Even without an advance directive, the patient's wishes should guide care
2. Non-maleficence - Avoiding interventions that may cause suffering without benefit
3. Beneficence - Providing appropriate care that aligns with the patient's goals
4. Justice - Appropriate use of medical resources

Family Consultation as First Step

The American College of Emergency Physicians (ACEP) clearly states that emergency physicians should "assist surrogates to make end-of-life care choices for patients who lack decision-making capacity, based on the patient's own preferences, values, and goals" 1. This guidance directly supports consulting with family members as the appropriate first action.

Evidence-Based Approach

Futility Considerations

The American Heart Association (AHA) guidelines recognize that resuscitation efforts may be futile in certain circumstances:

• Terminal cancer represents a situation where CPR is likely to be futile, particularly in elderly patients 1
• Studies show extremely poor outcomes for CPR in patients with advanced cancer, especially those with poor performance status 2
• AHA guidelines acknowledge that "many of these patients may have been appropriate for consideration of [DNAR] order before the arrest" 1

Proper Decision-Making Process

When a patient lacks an advance directive but family members are present:

1. Consult family immediately to determine the patient's previously expressed wishes
2. Discuss the likely poor outcomes of resuscitation in terminal cancer
3. Make a determination based on substituted judgment (what the patient would want)

Important Considerations

• Do not delay consultation: Waiting for legal counsel or advance directive copies would unnecessarily prolong potentially unwanted resuscitation
• Do not automatically stop resuscitation: This would violate the patient's autonomy without knowing their wishes
• Do not automatically continue all efforts: This may conflict with the patient's wishes and values

Practical Application

1. Briefly step away from the resuscitation to speak with family members

2. Ask specific questions about:

   • Any verbal expressions of the patient's wishes regarding end-of-life care
   • The patient's values and goals in the context of terminal illness
   • Any previous discussions about resuscitation preferences

3. Document the conversation thoroughly

4. Resume or discontinue resuscitation based on this information

Common Pitfalls to Avoid

• Assuming all patients want full resuscitation: Studies show many terminally ill patients would decline CPR if properly informed 3
• Making unilateral decisions: ACEP guidelines emphasize the importance of involving family in decision-making 1
• Delaying family consultation: This can lead to unwanted resuscitation efforts and family distress

By consulting with the family immediately, the emergency physician respects the patient's autonomy while acknowledging the medical reality of the situation, aligning with both ethical principles and clinical guidelines.