Introduction

Sudden unexpected cardiac arrest is an event with often devastating consequences to the individual victim, family and friends. While some resuscitation attempts are successful with good long-term outcome, the majority are not, despite significant efforts and some improvements during the last decade.

Healthcare professionals are obliged to do what is necessary to protect and save lives. Society as a whole and especially emergency medical services (EMS), hospitals and other healthcare institutions need to plan for, organise and provide an appropriate response in case of sudden cardiac arrest. This often implies the use of many resources and high costs, especially in the more affluent countries. New technology and medical evidence and increasing expectations of the public have rendered ethical considerations an important part of any end-of-life intervention or decision. This includes achieving the best results for the individual patient, relatives and for society as whole by appropriate allocation of available resources.

Several considerations are required to ensure that decisions to attempt or withhold resuscitation attempts are appropriate, and that patients are treated with dignity. These decisions are complex and may be influenced by individual, international and local cultural, legal, traditional, religious, social and economic factors.^{1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11} x P.J. Baskett, A. Lim. The varying ethical attitudes towards resuscitation in Europe. Resuscitation 62 (2004) (267 - 273) Crossref. x D.E. da Costa, H. Ghazal, S. Al Khusaiby. Do not resuscitate orders and ethical decisions in a neonatal intensive care unit in a Muslim community. Arch Dis Child Fetal Neonatal Ed 86 (2002) (F115 - F119) x J. Richter, M. Eisemann, E. Zgonnikova. Doctors’ authoritarianism in end-of-life treatment decisions. A comparison between Russia, Sweden and Germany. J Med Ethics 27 (2001) (186 - 191) Crossref. x R. De Leeuw, M. Cuttini, M. Nadai, et al.. Treatment choices for extremely preterm infants: an international perspective. J Pediatr 137 (2000) (608 - 616) Crossref. x C.L. Sprung, S.L. Cohen, P. Sjokvist, et al.. End-of-life practices in European intensive care units: the ethicus study. JAMA 290 (2003) (790 - 797) Crossref. x N.K. Ho. Decision-making: initiation and withdrawing life support in the asphyxiated infants in developing countries. Singapore Med J 42 (2001) (402 - 405) x M. Cuttini, M. Nadai, M. Kaminski, et al.. End-of-life decisions in neonatal intensive care: physicians’ self-reported practices in seven European countries. Lancet 355 (2000) (2112 - 2118) Crossref. x E. Konishi. Nurses’ attitudes towards developing a do not resuscitate policy in Japan. Nursing Ethics 5 (1998) (218 - 227) Crossref. x J.H. Muller, B. Desmond. Ethical dilemmas in a cross-cultural context. A Chinese example. West J Med 157 (1992) (323 - 327) x Edgren E. The ethics of resuscitation, differences between Europe and the USA—Europe should not adopt American guidelines without debate. Resuscitation 1992;23:85–90. x H.-H. Bülow, C. Sprung, K. Reinhart, et al.. The world's major religions’ points of viewon end-of-life decisions in the intensive care unit. Intens Care Med 34 (2008) (423 - 430)

Sometimes the decisions can be made in advance, but often these difficult decisions have to be made in a matter of seconds or minutes at the time of the emergency and especially in the out-of-hospital setting, based upon limited information. Therefore it is important that healthcare providers understand the principles involved before they are faced with a situation where a decision to resuscitate or not must be made. For healthcare professionals end-of-life decisions and ethical considerations should be made in advance and in the context of the society. Although there is little science to guide end-of-life decision-making, the subject is important, which is why information for healthcare providers is included in these resuscitation guidelines.

This section of the guidelines deals with some recurring ethical aspects and end-of-life decisions.

• Key principles of ethics
• Sudden death in a global perspective
• Outcome and prognostication
• When to start and when to stop resuscitation attempts
• Advance directives and do-not-attempt resuscitation orders
• Organ procurement
• Family presence during resuscitation
• Research in resuscitation and informed consent
• Research and training on the recently dead