Hostname: page-component-745bb68f8f-hvd4g Total loading time: 0 Render date: 2025-02-11T09:32:00.947Z Has data issue: false hasContentIssue false
  • English
  • Français

Cardiopulmonary Resuscitation in Resource-limited Health Systems–Considerations for Training and Delivery

Published online by Cambridge University Press:  19 November 2014

Jason Friesen ,
Dean Patterson  and
Kevin Munjal
Jason Friesen*
Affiliation:
Columbia University, Mailman School of Public Health, Department of Health Policy and Management, New York, New YorkUSA
Dean Patterson
Affiliation:
Columbia University, Mailman School of Public Health, Department of Health Policy and Management, New York, New YorkUSA
Kevin Munjal
Affiliation:
Mt. Sinai Medical Center, Department of Emergency Medicine, New York, New YorkUSA
*
Correspondence: Jason Friesen, MPH, EMT-P Columbia University Mailman School of Public Health Department of Health Policy and Management 375 South End Ave. #35R New York, New York 10280 USA E-mail jfriesen@trekmedics.org
Rights & Permissions [Opens in a new window]

Abstract

In the past 50 years, cardiopulmonary resuscitation (CPR) has gained widespread recognition as a life-saving skill that can be taught successfully to the general public. Cardiopulmonary resuscitation can be considered a cost-effective intervention that requires minimal classroom training and low-cost equipment and supplies; it is commonly taught throughout much of the developed world. But, the simplicity of CPR training and its access for the general public may be misleading, as outcomes for patients in cardiopulmonary arrest are poor and survival is dependent upon a comprehensive “chain-of-survival,” which is something not achieved easily in resource-limited health care settings. In addition to the significant financial and physical resources needed to both train and develop basic CPR capabilities within a community, there is a range of ethical questions that should also be considered. This report describes some of the financial and ethical challenges that might result from CPR training in low- and middle-income countries (LMICs). It is determined that for many health care systems, CPR training may have financial and ethically-deleterious, unintended consequences. Evidence shows Basic Life Support (BLS) skills training in a community is an effective intervention to improve public health. But, health care systems with limited resources should include CPR training only after considering the full implications of that intervention.

FriesenJ, PattersonD, MunjalK. Cardiopulmonary Resuscitation in Resource-limited Health Systems–Considerations for Training and Delivery. Prehosp Disaster Med. 2015;30(1):1-5.

Keywords

cardiopulmonary resuscitationcommunity health workerlow- and middle-income countriesmedical ethicstraining
Type
Special Report
Information
Prehospital and Disaster Medicine , Volume 30 , Issue 1 , February 2015 , pp. 97 - 101
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2014 

Background

The Necessity of Basic Life Support (BLS) Training in Resource-poor Settings

In the past 50 years, cardiopulmonary resuscitation (CPR) has gained widespread recognition as a life-saving skill that can be taught successfully to the general public.Reference Kouwenhoven, Jude and Knickerbocker 1 Specifically, BLS training for the public that includes basic first aid and CPR has been advocated as a low-cost, high-impact intervention to improve outcomes for medical emergencies.Reference Sasser, Varghese, Kellermann and Lormand 2 This training has been recommended by international health organizations and practitioners as an effective tool to mitigate preventable death and disability in low- and middle-income countries (LMICs).Reference Anderson, Suter and Mulligan 3 - Reference Gilbert 6

Cardiopulmonary resuscitation training for laypersons in LMICs could be an attractive public health training initiative because it is simple to perform, is of low training costs, and can be taught to a wide cross-section of a given population. The proliferation of international emergency medicine trainingReference Morton and Vu 7 , Reference Sistenich 8 has provided new opportunities to begin to investigate the costs and benefits of CPR training in resource-limited health care systems.Reference Meaney, Sutton and Tsima 9 This report aims to contribute to the discussion of CPR training in LMICs by considering challenges for health care educators, public health officials, policy makers, and other stakeholders.

Cardiopulmonary Resuscitation Outcomes

Taken at face value, CPR training for laypersons in LMIC health care systems may seem an effective way to mitigate preventable death and disability. Although it comprises only one component of the standard BLS curriculum, CPR involves the recognition of choking victims and cardiac arrest, the performance of basic airway management, chest compressions, and use of an automatic external defibrillator (AED), if available. According to the American Heart Association (Dallas, Texas USA), CPR requires only four hours of instruction, and can be learned by children as young as nine-years-old.Reference Fleischhack, Nuernberger and Sterz 10 With these minimal requirements, and the intervention known to literally “save lives,” it can be perceived as a cost-effective intervention.

However, despite widespread CPR education and the existence of robust prehospital Emergency Medical Services (EMS) systems throughout resource-rich countries, outcomes remain poor overall.Reference Wampler, Collett and Manifold 11 A 2010 systematic review of 67 international studies places the global survival rate at around seven percent.Reference Berdowski, Berg, Tijssen and Koster 12 Similarly, a 2010 meta-analysis of 26 countries determined a crude rate of 6.6% (n = 1,162) for survival to discharge among patients achieving prehospital return of spontaneous circulation (ROSC) after cardiopulmonary collapse.Reference Sasson, Rogers, Dahl and Kellermann 13 Also noted was that, “survival from [out-of-hospital cardiac arrest] has not significantly improved in almost 30 years.”Reference Sasson, Rogers, Dahl and Kellermann 13 In 2008, Nichol et al reported 7.9% (n ~ 710) survival for nontraumatic cardiac arrest to hospital discharge in ten hospitals in the US and Canada.Reference Nichol, Thomas and Callaway 14 In Japan, another country with advanced prehospital cardiac care provided by nonphysicians, a 5-year retrospective study published in 2012 found that sustained ROSC was obtained in 10% of patients (n = 17,020), with 1-month survival equaling 7.6% (n = 12,861).Reference Kitamura, Iwami and Kawamura 15

Survival for traumatic arrest is still worse, ranging between 1.3% and three percent for blunt traumaReference Stratton, Brickett and Crammer 16 , Reference Moriwaki, Sugiyama and Yamamoto 17 and between 0.8% and four percent for penetrating trauma.Reference Stratton, Brickett and Crammer 16 , Reference Battistella, Nugent, Owings and Anderson 18 Among all-cause pediatric arrests, survival to discharge ranges between 6.7% and 8.6%.Reference Donoghue, Nadkarni and Berg 19 , Reference Young 20

While statistics on survival may vary slightly dependent upon etiology, in all cases, only a fraction of these survivors have favorable neurologic outcomes. If the rates cited above are demonstrative of what can be achieved in developed nations with significantly more resources available, the expectations for what can be achieved through CPR training in resource-limited health settings should be tempered. While recently reported outcomes may show incremental gains for cardiac arrest patients, these improvements increasingly involve new or emerging therapies, including therapeutic hypothermia.

The Chain-of-Survival

Effective survival with CPR in out-of-hospital cardiac arrest (OHCA) is predicated upon the “chain-of-survival” concept.Reference Cummins, Ornato, Thies and Pepe 21 This chain is an integrated continuum of care that includes community-wide CPR training, public access to AEDs, a robust prehospital emergency care system, and health care facilities with the capacity to both continue resuscitative efforts and provide integrated and intensive post resuscitative care and rehabilitation. Without a complete and functioning chain-of-survival, LMIC communities will have a low chance of duplicating outcomes achieved in more affluent countries. With this in mind, the notion that OHCA could be a target for a low-cost, public health intervention is no longer straight forward. It nonetheless remains a popular, persistent recommendation for health development programs in LMICs, 22 perhaps to the detriment of other, more effective BLS skills.

Cardiopulmonary Resuscitation Training and In-hospital Cardiac Arrest (IHCA)

On the other hand, CPR training for in-hospital use may prove worthwhile. US studies have shown that IHCAs have better outcomes than OHCAs,Reference Merchant, Yang and Becker 23 , Reference Meaney, Nadkarni, Kern, Indik, Halperin and Berg 24 and that outcomes for this group are improving.Reference Girotra, Nallamothu and Spertus 25 This is likely due to increased probability of witnessed arrest and available advanced cardiac care.Reference Nolan 26 However, the opportunity costs might still be too high for many health care facilities because advanced resuscitative care is costly. A 2008 study from Germany found the cost per admitted patient after ROSC was €21,166 (US $26,451);Reference Graf, Muhlhoff and Doig 27 a 2004 study from Norway reported that the “survivors” from cardiac arrest cost €40,462 (US $50,565) per patient discharged alive;Reference Naess and Steen 28 and a 2009 study examining the costs of in-hospital pediatric cardiac arrest in the UK reported that the mean cost of resuscitation was £3,884 (US $6,203), the mean-cost for post resuscitative length of stay was £22,562 (US $36,033), the annual costs for CPR preparedness were £181,565 (US $289,971), and the cost per survivor to discharge was £53,289 (US $85,106).Reference Duncan and Frew 29 Unfortunately, it would seem that few health systems in LMICs would have the health care infrastructure in place to achieve sophisticated post resuscitative care (including both physical and human resources), as well as the financial resources to maintain this infrastructure. Without a complete and functioning chain-of-survival, developing communities will have little expectation of replicating outcomes comparable to those in wealthy countries.

Ethical Considerations

While the economic realities of post resuscitative care in resource-limited health systems are clear, it is perhaps more important to examine the ethical issues surrounding CPR training in these same communities. For many, the idea of withholding CPR training and education may seem unethical, especially to those clinical providers and laypersons who recognize the utility of CPR as a life-saving intervention. Given the more favorable prognosis among select etiologies (eg, near-drowningReference Suominen, Baillie, Korpela, Rautanen, Ranta and Olkkola 30 and open-heart surgeryReference Hilberman, Kutner, Parsons and Murphy 31 ) some health care systems may choose to teach or perform CPR despite a lack of adequate educational resources, necessary equipment, supplies, and personnel, as the decision to not provide CPR training potentially denies individuals and families a chance to survive a devastating event.

There is, at the same time, an expansive body of literature examining the ethics of CPR. Though the majority seems to assume the existence of a fully-operational chain-of-survival functioning within a robust health infrastructure that is capable of providing a recognized standard of care at all times, the concepts commonly used to frame discussions about the ethics of CPR (ie, patient autonomy, beneficence, and nonmaleficence) may be reasonably applied to differing societies, irrespective of socio-economic status. Given the relative paucity of existing discussion on the ethics of health training in resource-limited settings,Reference Iserson, Biros and Holliman 32 a few of the ethical considerations surrounding CPR are discussed here that may be relevant to communities and health systems with limited resources.

Patient Autonomy

Cardiopulmonary resuscitation, by its nature, makes informed consent virtually impossible. Western clinical providers are commonly trained to provide aggressive attempts at resuscitation unless presented with legally valid proof of the patient's or proxy's decision to forgo resuscitative efforts. This often results in providers acting first and asking questions only after resuscitation has begun. It also assumes that resuscitation is the correct thing to do. In LMICs where health education may be limited and literacy levels are low, the concept of “resuscitation,” or even “reanimation” in some languages, may be foreign to the society's social, cultural, and religious traditions, and inadvertently create misunderstandings that may have profound unintended consequences for health care providers, families, and the community.Reference Iserson, Biros and Holliman 32 Ardagh points out, “the process of achieving proxy consent is an unfair burden to place upon the patient's relatives or loved ones… [and] urgency in itself is coercive and it limits the time available for adequate informing and deliberation.”Reference Ardagh 33 This problem is further exacerbated when nonphysician providers, including laypersons with less education and experience, have to make these decisions in the prehospital setting.Reference Guru, Verbeek and Morrison 34

The fragility of such situations is potentially greater in countries unfamiliar with common approaches to palliative and end-of-life care. Discussions with family and caregivers in these situations may be incompletely understood, or entirely alien, in communities with limited access to health care. The subsequent confusion among family members and caregivers regarding the risks and benefits of resuscitation may lead to adverse outcomes, including: (1) unnecessarily prolonging a patient's suffering through insufficient or incomplete resuscitative care; (2) delaying or confusing the administration and pronouncement of “last rites” in varied religious traditions;Reference Sheng, Lim and Rashidi 35 , Reference Sasson, Forman, Krass, Macy, Kellermann and McNally 36 or (3) complicating the coping and grieving processes in settings where the cultural and religious understandings of mind, body, and soul are not amenable to Western understandings and debates surrounding life and death.Reference Miljeteig and Norheim 37 , Reference Amy 38 In a 2003 article from Barbados examining the use of futility-of-care decisions in a hospital intensive care unit, Hariharan and colleagues reported, “there was no single case where the decision of futility of care was used to withhold life-support. Many physicians are hesitant to recognize futility of care because of religious beliefs, a feeling of guilt, and fear of litigation.”Reference Hariharan, Moseley, Kumar, Walrond and Jonnalagadda 39 Countries may also have medical-legal definitions of life, death, and euthanasia that may or may not be clearly articulated, creating additional areas for potential problems. Such wide-ranging dilemmas are regularly encountered during the administration of CPR, and may become more pronounced in resource-limited settings where fewer advances in medical care and technology have yet been introduced.Reference Illich 40

In settings with low health literacy among the indigenous populations, patient autonomy can be a far more difficult issue to define. Even in nations where resuscitation is common and widespread, the debates and legislation surrounding the definitions of life, death, and euthanasia may be contentious with the on-going arguments regularly played out in both academic and popular media venues.Reference Ardagh 41 , Reference Timmermans 42 The lack of a uniform approach to CPR among health systems in resource-rich countries is furthermore evidenced by the range of actual care provided.Reference Hilberman, Kutner, Parsons and Murphy 31 , Reference Iserson 43 - Reference Glover, Brown and Morrison 46

Beneficence

In resource-limited health care systems, the utilization of scarce resources can have a far greater impact on the well-being of a larger population. This is true in cases where limited medical supplies are intermittently available to a given population. Lack of health insurance may incur overwhelming debts for families who cannot cover the medical bills accrued during and after resuscitation.Reference Miljeteig and Norheim 37 These can be further exacerbated when the low probability of successful outcomes is not fully understood,Reference Diem, Lantos and Tulsky 47 or when outcomes that include chronic disability and decreased cognitive ability are possible.Reference Miljeteig, Sayeed, Jesani, Johansson and Norheim 48 In resource-poor health systems, the concept of beneficence, or acting in a person's best interest, may be justifiably applied to the view point of a family or an entire community when considering the effects of using limited resources. While withholding medical care for cardiac arrest patients could be seen as rationing, the opposite may be equally true in a resource-limited health care system; as Timmermans notes “Social scientists usually suggest that the solution to the negative effects of rationing is to increase accessibility for all populations; however, resuscitative efforts are a prime example where less access of all groups – instead of for some – might be preferable”Reference Timmermans 49 (italics in original). Additionally, there is also the question of the emotional and psychological toll that extended, futile attempts at resuscitation can have on health care workers and families alike.Reference Brindis, Gausche-Hill, Young and Putnam 50

Nonmaleficence

If health care providers are expected by the public to not inflict intentional harm upon their patients, proper regulatory measures need to be enacted to ensure that health care providers are providing an approved minimum standard of care. The administrative capacity also needs to exist to enforce accountability, maintain competency, and encourage continuing education for CPR skills and knowledge retention. It could be considered unethical to not expect the same standards for CPR training in LMICs as is expected in high-income countries.

The relative ease of CPR instruction should not, in itself, be a satisfactory justification for conducting CPR training courses in resource-limited health care systems. Without proper educational tools and regulatory capabilities, including, at a minimum, certification and refresher training to ensure that CPR is continuously delivered at a recognized, accredited standard, persons with limited health care knowledge and/or low literacy may inadvertently induce iatrogenic complications. Mock et al reported “a slight overreliance” on the use of mouth-to-mouth resuscitation under questionable circumstances;Reference Mock, Tiska, Adu-Ampofo and Boakye 51 in one author of this reports’ experience (JF), an overreliance on chest compressions when not indicated was also observed. In recent years, recognized international standards for CPR training have modified the instruction to now omit mouth-to-mouth resuscitation, but this should not assume that the information has been definitively disseminated in the interim. Paradoxically, the contrasting outcomes among neonatalReference Donoghue, Nadkarni and Berg 19 , Reference Lawn, Zupan, Begkoyian and Knippenberg 52 and pediatric arrestReference Atkins, Everson-Stewart and Sears 53 versus geriatric arrest, or witnessed versus unwitnessed arrest,Reference Donoghue, Nadkarni and Berg 19 , Reference Iserson 43 , Reference Herlitz, Bahr, Fischer, KUISMA, Lexow and Thorgeirsson 54 can pose other dilemmas for educators and policy makers.

Finally, it is well documented that cardiac arrest patients being transported rapidly to a medical facility put pedestrians at unnecessary risk of injury, including the patient, transporting providers, and the general public.Reference Maguire 55 Thus, the defining principle of nonmaleficence, “first, do no harm,” can be reasonably applied as well to emergency responders and other road users, particularly when resuscitative efforts are unlikely to produce successful outcomes.Reference Rosemurgy, Norris, Olson, Hurst and Albrink 56 This is further supported by a 2012 study that described 0.69% survival to discharge for OHCA patients who did not achieve ROSC prior to arrival at the hospital.Reference Wampler, Collett and Manifold 11

Potential Guidance

The decision to provide training for, and delivery of, CPR within a resource-limited health care system should be made only after performing a thorough examination of the financial and ethical implications for the local community and including the public in an open and honest discussion regarding these issues. The following practical considerations may help stakeholders more accurately assess the logistical feasibility of starting, or continuing, a CPR training program in resource-limited health care systems; if answers cannot be provided, the probability of positive outcomes after CPR decrease:

  1. 1. Access – How do members of the community access the health care system in the event of an emergency? How reliable are communications and community-based care systems? Are there areas in the community that have limited or no access to emergency care?

  2. 2. Prehospital Care – What does care in the prehospital environment look like? Who are the prehospital care providers in your community and what is their training level? What resources and equipment are available to them? Are there areas in the community that are not reached by prehospital care services?

  3. 3. Definitive Care – Are clinical providers and facilities equipped to provide on-going and post resuscitative care? Are protocols in place to determine futility of care and termination of resuscitation?

  4. 4. Chronic Care – Are there resources available for potentially long-term rehabilitation? What stigmas exist among the community regarding the social status of disabled persons?

  5. 5. Health Care Finance – How is this care to be financed? Is it the patient's and their family's responsibility? Does the community share the cost? Is there an insurance market?

When determining the ethical implications of CPR training and delivery in different socio-cultural contexts, it is strongly recommended to consider existing legislation, including legal definitions and parameters for emergency care, consent, duty to act, and other “Good Samaritan” laws for both prehospital and clinical providers, as well as bystanders. Legislation may need to be updated to remain consistent with ethical consensus and newly-defined societal expectations around sudden cardiac arrest.

Conclusion

Cardiopulmonary resuscitation training has gained widespread recognition in affluent countries for being a simple and accessible life-saving skill. Owing in large part to these factors, health practitioners from these countries involved in international health development initiatives often cite CPR as a valuable skill and are increasingly encouraging its dissemination throughout LMICs. This report offers some further considerations for health care providers and policy makers who may be considering such initiatives, illustrating a few of the many financial and ethical issues that can present themselves when exporting advanced health interventions from affluent countries to resource-limited health systems. Health systems and the communities they serve must decide for themselves if CPR is an appropriate health intervention to provide, but should do so only after a concerted effort by appropriate stakeholders to examine the effects that implementing aggressive resuscitative care might have on their community.

Footnotes

Conflicts of interest: none

References

1. Kouwenhoven, W, Jude, J, Knickerbocker, GG. Closed-chest cardiac massage. JAMA. 1960;173(10):1064-1067.Google Scholar
2. Sasser, S, Varghese, M, Kellermann, A, Lormand, JD. Prehospital Trauma Care Systems. Geneva, Switzerland: World Health Organization; 2005.Google Scholar
3. Anderson, PD, Suter, RE, Mulligan, T, et al. World Health Assembly Resolution 60.22 and its importance as health care policy tool for improving emergency care access and availability globally. Ann Emerg Med. 2012;60(1):35-44.Google Scholar
4. Kobusingye, O, Hyder, A, Bishai, D, et al. “Emergency Medical Services.” In: Jamison D, (ed). Disease Control Priorities Project. Washington DC, USA: The World Bank; 2011:1261-1279.Google Scholar
5. Nielsen, K, Mock, C, Joshipura, M, et al. Assessment of the status of prehospital care in 13 low- and middle-income countries. Prehosp Emerg Care. 2012;16(3):381-389.Google Scholar
6. Gilbert, M. Bridging the gap: building local resilience and competencies in remote communities. Prehosp Disaster Med. 2008;23(4):297-300.Google Scholar
7. Morton, MJ, Vu, A. International emergency medicine and global health: training and career paths for emergency medicine residents. Ann Emerg Med. 2011;57(5):520-525.Google Scholar
8. Sistenich, V. International emergency medicine: how to train for it. Emerg Med Australas. 2012;24(4):435-441.Google Scholar
9. Meaney, PA, Sutton, RM, Tsima, B, et al. Training hospital providers in basic CPR skills in Botswana: acquisition, retention, and impact of novel training techniques. Resusc. 2012;83(12):1484-1490.Google Scholar
10. Fleischhack, R, Nuernberger, A, Sterz, F, et al. School children sufficiently apply life supporting first aid: a prospective investigation. Crit Care. 2009;13(4):R127.Google Scholar
11. Wampler, DA, Collett, L, Manifold, CA, et al. Cardiac arrest survival is rare without prehospital return of spontaneous circulation. Prehosp Emerg Care. 2012;16(4):451-455.Google Scholar
12. Berdowski, J, Berg, RA, Tijssen, JGP, Koster, RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resusc. 2010;81(11):1479-1487.Google Scholar
13. Sasson, C, Rogers, MAM, Dahl, J, Kellermann, AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ. 2010;3(1):63-81.Google Scholar
14. Nichol, G, Thomas, E, Callaway, CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300(12):1423-1431.Google Scholar
15. Kitamura, T, Iwami, T, Kawamura, T, et al. Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan. Circ. 2012;126(24):2834-2843.Google Scholar
16. Stratton, SJ, Brickett, K, Crammer, T. Prehospital pulseless, unconscious penetrating trauma victims: field assessments associated with survival. J Trauma. 1998;45(1):96-100.Google Scholar
17. Moriwaki, Y, Sugiyama, M, Yamamoto, T, et al. Outcomes from prehospital cardiac arrest in blunt trauma patients. World J. Surg. 2011;35(1):34-42.Google Scholar
18. Battistella, FD, Nugent, W, Owings, JT, Anderson, JT. Field triage of the pulseless trauma patient. Arch Surg. 1999;134(7):742-745.Google Scholar
19. Donoghue, A, Nadkarni, V, Berg, R, et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med. 2005;46(6):512-522.Google Scholar
20. Young, KD. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatr. 2004;114(1):157-164.Google Scholar
21. Cummins, RO, Ornato, JP, Thies, WH, Pepe, P. Improving survival from sudden cardiac arrest: the “chain of survival” concept. Circ. 2005;83(5):1832-1847.Google Scholar
22. International Federation of Red Cross. First Aid for a Safer Future – Advocacy Report 2010. Geneva, Switzerland; 2010.Google Scholar
23. Merchant, RM, Yang, L, Becker, LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401-2406.Google Scholar
24. Meaney, PA, Nadkarni, VM, Kern, KB, Indik, JH, Halperin, HR, Berg, RA. Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med. 2010;38(1):101-108.Google Scholar
25. Girotra, S, Nallamothu, BK, Spertus, JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912-1920.Google Scholar
26. Nolan, JP. Cardiopulmonary resuscitation. BMJ. 2012;345:e6122.Google Scholar
27. Graf, J, Muhlhoff, C, Doig, GS, et al. Health care costs, long-term survival, and quality of life following intensive care unit admission after cardiac arrest. Crit Care. 2008;12(4):R92.Google Scholar
28. Naess, AC, Steen, PA. Long term survival and costs per life year gained after out-of-hospital cardiac arrest. Resusc. 2004;60(1):57-64.Google Scholar
29. Duncan, HP, Frew, E. Short-term health system costs of paediatric in-hospital acute life-threatening events including cardiac arrest. Resusc. 2009;80(5):529-534.Google Scholar
30. Suominen, P, Baillie, C, Korpela, R, Rautanen, S, Ranta, S, Olkkola, KT. Impact of age, submersion time, and water temperature on outcome in near-drowning. Resusc. 2002;52(3):247-254.Google Scholar
31. Hilberman, M, Kutner, J, Parsons, D, Murphy, DJ. Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR). J Med Ethics. 1997;23(6):361-367.CrossRefGoogle ScholarPubMed
32. Iserson, KV, Biros, MH, Holliman, CJ. Challenges in international medicine: ethical dilemmas, unanticipated consequences, and accepting limitations. Acad Emerg Med. 2012;19(6):683-692.Google Scholar
33. Ardagh, M. Resurrecting autonomy during resuscitation--the concept of professional substituted judgment. J Med Ethics. 1999;25(5):375-378.Google Scholar
34. Guru, V, Verbeek, PR, Morrison, LJ. Response of paramedics to terminally ill patients with cardiac arrest: an ethical dilemma. CMAJ. 1999;161(10):1251-1254.Google ScholarPubMed
35. Sheng, CK, Lim, CK, Rashidi, A. A multi-center study on the attitudes of Malaysian emergency health care staff towards allowing family presence during resuscitation of adult patients. Int J Emerg Med. 2010;3(4):287-291.Google Scholar
36. Sasson, C, Forman, J, Krass, D, Macy, M, Kellermann, AL, McNally, BF. A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols. Circulation: cardiovascular quality and outcomes. Am Heart Assoc. 2009;2(4):361-368.Google Scholar
37. Miljeteig, II, Norheim, OFO. My job is to keep him alive, but what about his brother and sister? How Indian doctors experience ethical dilemmas in neonatal medicine. Developing World Bioethics. 2006;6(1):23-32.Google Scholar
38. Amy, Wilentz. “A Zombie Is A Slave Forever.” New York Times, New York USA; Op-Ed. October 30, 2012.Google Scholar
39. Hariharan, S, Moseley, HSL, Kumar, AY, Walrond, ER, Jonnalagadda, R. Futility-of-care decisions in the treatment of moribund intensive care patients in a developing country. Can J Anaesth. 2003;50(8):847-852.Google Scholar
40. Illich, I. Medical nemesis. Lancet. 1974;1(7863):918-921.Google Scholar
41. Ardagh, M. Futility has no utility in resuscitation medicine. J Med Ethics. 2000;26(5):396-399.Google Scholar
42. Timmermans, S. High touch in high tech: the presence of relatives and friends during resuscitative efforts. Sch Inq Nurs Pract. 1997;11(2):153-168; discussion 169-173.Google Scholar
43. Iserson, KV. Resuscitation strategies in the United States: realities of hospital and prehospital treatment. Am J Bioethics. 2010;10(1):72-73.CrossRefGoogle ScholarPubMed
44. Handley, AJ. Compression-only CPR—to teach or not to teach? Resusc. 2009;80(7):752-754.Google Scholar
45. Kämäräinen, A, Virkkunen, I, Yli-Hankala, A, Silfvast, T. Presumed futility in paramedic-treated out-of-hospital cardiac arrest: an Utstein style analysis in Tampere, Finland. Resusc. 2007;75(2):235-243.Google Scholar
46. Glover, BM, Brown, SP, Morrison, L, et al. Wide variability in drug use in out-of-hospital cardiac arrest: a report from the resuscitation outcomes consortium. Resusc. 2011;83(11):1324-1330.Google Scholar
47. Diem, SJ, Lantos, JD, Tulsky, JA. Cardiopulmonary resuscitation on television: miracles and misinformation. N Engl J Med. 1996;334(24):1578-1582.Google Scholar
48. Miljeteig, I, Sayeed, SA, Jesani, A, Johansson, KA, Norheim, OF. Impact of ethics and economics on end-of-life decisions in an Indian neonatal unit. Pediatrs. 2009;124(2):e322-e328.Google Scholar
49. Timmermans, S. When death isn't dead: implicit social rationing during resuscitative efforts. Sociol Inq. 2007;69(1):51-75.Google Scholar
50. Brindis, SL, Gausche-Hill, M, Young, KD, Putnam, B. Universally poor outcomes of pediatric traumatic arrest: a prospective case series and review of the literature. Pediatr Emerg Care. 2011;27(7):616-621.Google Scholar
51. Mock, CN, Tiska, M, Adu-Ampofo, M, Boakye, G. Improvements in prehospital trauma care in an African country with no formal Emergency Medical Services. J Trauma. 2002;53(1):90-97.Google Scholar
52. Lawn, JE, Zupan, J, Begkoyian, G, Knippenberg, R. “Newborn Survival.” In: Jamison DT, Breman JG, Measham AR, et al, (eds). Disease Control Priorities in Developing Countries. 2nd ed. New York, New York USA: Oxford University Press; 2006:531-549.Google Scholar
53. Atkins, DL, Everson-Stewart, S, Sears, GK, et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children. Circ. 2009;119(11):1484-1491.Google Scholar
54. Herlitz, J, Bahr, J, Fischer, M, KUISMA, M, Lexow, K, Thorgeirsson, G. Resuscitation in Europe: a tale of five European regions. Resuscitation. 1999;41(2):121-131.Google Scholar
55. Maguire, B. Transportation-related injuries and fatalities among Emergency Medical Technicans and Paramedics. Prehosp Disaster Med. 2011;26(4):1-7.Google Scholar
56. Rosemurgy, AS, Norris, PA, Olson, SM, Hurst, JM, Albrink, MH. Prehospital traumatic cardiac arrest: the cost of futility. J Trauma. 1993;35(3):468-473; discussion 473-474.Google Scholar