The first time I did CPR, coagulated blood spurted onto my new white coat from a wound in the patient’s chest. Another time a patient’s urine soaked through the knees of my pants as I knelt at his side.
Even in the best of conditions, cardiopulmonary resuscitation (CPR) is a spit-smeared, bloody business that can expose health care workers to all kinds of body fluids. Like all health care workers, I put on gloves and a game face and accept such things as part of patient care.
The 2014 Ebola outbreak changes all that. Hospitals all around the world are now training staff in personal protective equipment (PPE) use and convening rapid response teams. A key part of this process involves grappling with how dangerous it will be to perform CPR on patients with Ebola.
Fully 70 percent of those stricken with Ebola in 2014 have died. That means in countries like the United States where we attempt CPR routinely to save dying patients, health care workers will be called to resuscitate Ebola patients.
From placement of an artificial airway to the administration of chest compressions and beyond, each step in CPR can expose health care workers to body fluids containing as many as a million viral particles in each drop and well-proven to transmit Ebola. In contradistinction to the bowling alley and subway exposures that have drawn so much media attention, health care workers performing CPR on Ebola patients will truly be in the direct line of viral fire.
Guidance for CPR Use
The Centers for Disease Control and Prevention (CDC) provides some guidance to first responders in a guide released on October 1. Of CPR and other invasive procedures, the CDC says, “Performing these procedures in a less controlled environment (e.g., moving vehicle) increases risk of exposure for EMS personnel. If conducted, perform these procedures under safer circumstances (e.g., stopped vehicle, hospital destination).”
The phrase “if conducted” implies a lot. It suggests health care workers may opt to let a patient die if they think it’s too unsafe to try to save them.
It is wrong to leave so much unsaid. We should not ask health care workers to make ethically fraught and perilous choices about whether to resuscitate a patient with Ebola while working alone in the back of an ambulance or from the doorway of a hospital room with the heart monitor squalling.
Instead we should adopt clear and explicit policies telling providers in advance when they should, and shouldn’t, resuscitate patients with Ebola. A simple checklist posted on the door of a patient being treated for Ebola virus disease should specify which safety gear and which equipment must be present for CPR to continue. And if not, providers should stand by, and withhold CPR.
There is precedent for withholding CPR to dying patients. The Medical Ethics Manual of the World Medical Association states, “physicians must balance their responsibility for their own safety and well-being and that of their staff with their duty to promote the well-being of the patients.” Accordingly, Doctors without Borders recently decided not to undertake resuscitation in children with Ebola virus disease because it was deemed too unsafe. And, as with any illness, if the patient is too sick to benefit from resuscitation, or declines CPR, then CPR should not be done. US Ebola patient Thomas Eric Duncan reportedly declined CPR, and died soon after.
Yet this interdiction against CPR in patients with Ebola can be taken too far. Bioethicist Professor Joseph Fins of the Weill Medical College of Cornell University recently suggested we withhold CPR in all patients with Ebola. He wrote, “There is no available therapy for Ebola, all the more so for patients in extremis. This makes resuscitation an act of futility and a symbolic homage to a mistaken notion of patient autonomy.” An article in The New York Times cited other ethicists who agree with Fins.
I disagree. We just don’t know enough to issue a blanket prohibition of CPR for patients with Ebola. Some patients with Ebola may present with electrolyte disturbances that could be fixed easily during a resuscitation attempt. Others may present with hopeless end-stage multi-organ failure. Until we know what proportion of each type of patient our hospitals will face, we should avoid premature proclamations and the needless loss of life they can bring.
There are positive signs we can provide aggressive medical care to patients with Ebola safely. Shortly after describing basic clinical care for US patients with Ebola, clinicians at Emory recently reported successful delivery of renal replacement therapy to one patient with Ebola virus disease who developed acute kidney injury. To date there have been no cases of Ebola virus transmission at Emory, suggesting that aggressive lifesaving therapy can be delivered at well-prepared US medical centers without substantial risk of transmission to health care workers.
All patients with Ebola deserve excellent care, and health care workers should be safe when providing it. We must ensure we celebrate the determination and compassion we showed while pushing this deadly virus back into the jungle. Along those same lines, I hope we will be proud of the ethical and transparent way we balanced the health of our Ebola patients with the wellbeing of the heroes who care for them.