Nearly 5,000 out-of-hospital cardiac arrests occur annually in Denmark. Three in four take place in the patient’s home, often witnessed by relatives. In 60–70

This article features an exemplary case of a terminally ill man with a do-not-resuscitate (DNR) order who is subject to a resuscitation attempt after suffering an out-of-hospital cardiac arrest (OHCA). The case is explored for its philosophical implications in the broader perspective of medical ethics. It is argued that the metaphysics of modern medical practice seems to have shifted away from the overall purpose and meaning of medical intervention to a primary concern with immediate effects of treatment, led on by medical advances and strict adherence to standard procedures. Whether it being the attempted resuscitation of a terminally ill patient in cardiac arrest, or the overtreatment of terminally ill or dying patients in general. In this article it is concluded that the best overall pre-hospital care is not achieved by adherence to standard procedures alone but also rests on the recognition and support of emergency medical technicians (EMTs) as moral agents, capable of exercising moral judgment based on the individual patients’ situation. Our intention is not to critique the actions of individuals, nor do we make claims about frequency of occurrence. Rather, we draw attention to a general shift in focus and mode of thinking in the Danish healthcare system to discuss solutions. The study was approved by University of Southern Denmark’s Ethics Committee. Written informed consent to participate and publish was obtained from the participant. This study was supported by the Danish Air Ambulance.

BACKGROUND:Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA.METHODS:We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis.RESULTS:All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values.CONCLUSION:This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.

The Elgar Encyclopedia of Human Rights is the most comprehensive reference work in the field of international human rights protection. Comprising over 340 entries, presented alphabetically, and available online and in print, the Encyclopedia addresses the full range of themes associated with the study and practice of human rights in the modern world. The topics range from substantive human rights to the relevant institutions, legal documents, conceptual and procedural issues of international law and a wide variety of thematic entries. The Encyclopedia has a distinct focus on international human rights law but at the same time is enriched by approaches from the broader social, sciences making it a truly unique and multi-disciplinary resource.

Aim This systematic review explored how non-medical factors influence the prehospital resuscitation providers’ decisions whether or not to resuscitate adult patients with cardiac arrest. Methods We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings. Results We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient’s characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers’ characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers’ had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests. Conclusions Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest.

Background Decision-making in out-of-hospital cardiac arrest should ideally include clinical and ethical factors. Little is known about the extent of ethical considerations and their influence on prehospital resuscitation. We aimed to determine the transparency in medical records regarding decision-making in prehospital resuscitation with a specific focus on ethically relevant information and consideration in resuscitation providers’ documentation. Methods This was a Danish nationwide retrospective observational study of out-of-hospital cardiac arrests from 2016 through 2018. After an initial screening using broadly defined inclusion criteria, two experienced philosophers performed a qualitative content analysis of the included medical records according to a preliminary codebook. We identified ethically relevant content in free-text fields and categorised the information according to Beauchamp and Childress’ four basic bioethical principles: autonomy, non-maleficence, beneficence, and justice. Results Of 16,495 medical records, we identified 759 (4.6%) with potentially relevant information; 710 records (4.3%) contained ethically relevant information, whereas 49 did not. In general, the documentation was vague and unclear. We identified four kinds of ethically relevant information: patients’ wishes and perspectives on life; relatives’ wishes and perspectives on patients’ life; healthcare professionals’ opinions and perspectives on resuscitation; and do-not-resuscitate orders. We identified some “best practice” examples that included all perspectives of decision-making. Conclusions There is sparse and unclear evidence on ethically relevant information in the medical records documenting resuscitation after out-of-hospital cardiac arrests. However, the “best practice” examples show that providing sufficient documentation of decision-making is, in fact, feasible. To ensure transparency surrounding prehospital decisions in cardiac arrests, we believe that it is necessary to ensure more systematic documentation of decision-making in prehospital resuscitation.

The “morning morality effect”—the alleged phenomenon that people are more likely to act in unethical ways in the afternoon when they are tired and have less self-control than in the morning—may well be expected to influence prehospital anaesthesiologist manning mobile emergency care units (MECUs). The working conditions of these units routinely entail fatigue, hunger, sleep deprivation and other physical or emotional conditions that might make prehospital units predisposed to exhibit the “morning morality effect”. We investigated whether this is in fact the case by looking at the distribution of patient transports to hospital with and without physician escort late at night at the end of the shift as a surrogate marker for changing thresholds in ethical behaviour. All missions over a period of 11 years in the MECU in Odense were reviewed. Physician-escorted transports to hospital were compared with non-physician-escorted transports during daytime, evening, and night-time (which correlates with time on the 24 h shifts). In total, 26,883 patients were transported to hospital following treatment by the MECU. Of these, 27.4% (26.9%–27.9%) were escorted to the hospital. The ratio of patient transports to hospital with and without physician escort during the three periods of the day did not differ (p = 1.00). We found no evidence of changes in admission patterns over the day. Thus, no evidence of the expected “morning morality effect” could be found in a prehospital physician-manned emergency care unit.

BACKGROUND:Discussions on ethical aspects of life-and-death decisions within the hospital are often made in plenary. The prehospital physician, however, may be faced with ethical dilemmas in life-and-death decisions when time-critical decisions to initiate or refrain from resuscitative efforts need to be taken without the possibility to discuss matters with colleagues. Little is known whether these considerations regarding ethical issues in crucial life-and-death decisions are documented prehospitally. This is a review of the ethical considerations documented in the prehospital medical records of patients in a Danish prehospital setting for whom the decision to resuscitate or not was made at the scene.METHODS:The study is based on discharge summaries of all patients subjected to crucial life-and-death decisions by the Mobile Emergency Care Unit in Odense in the years 2010 to 2014. The medical records with possible documentation of ethical issues were independently reviewed by two philosophers in order to identify explicit ethical or philosophical considerations pertaining to the decision to resuscitate or not.RESULTS:In total, 1275 patients were either declared dead at the scene without exhibiting layman's reliable signs of death or admitted to hospital following resuscitation. In a total of 62 patients, 85 specific ethical issues related to resuscitation were documented. The expressions of the ethical considerations were generally vague or unclear and almost exclusively concerned the interests of the patient and not the relatives. In the vast majority of cases where an ethical content was identified, the ethical considerations led to a decision to terminate treatment.CONCLUSIONS:A strengthened practice of documenting ethical considerations in prehospital life-and-death decision-making in the patient's medical records is required. We suggest that a template be implemented in the prehospital medical records describing the basis for any ethical decisions. This template should contain information regarding the persons involved in the deliberations and notes on ethical considerations. The documentation should include considerations concerning the patient's end-of-life wishes, the estimations of the quality of life before and after the incident, and a summary of other ethical concerns taken into account, such as the integrity of the patient and frame of mind of relatives.

BackgroundWe aimed to see if a novel credit card size cardiopulmonary resuscitation (CPR) feedback device helped to improve the quality of chest compressions by lay participants compared to compressions done without feedback. Materials and methodsThis study had non-healthcare workers aged 25 -70 years old randomized into either a real-time feedback group that got the CPRcard, which provided real-time feedback for both chest compression rate and depth, or the no feedback group.Participants in the control group (no feedback) either used a blinded CPRcard or performed compressions without a CPRcard. ResultsParticipants in the CPRcard group achieved a better median compression rate (CPRcard: 117 vs control: 122, p-value = 0.001) and higher proportion of compressions within the adequate range of 100 to 120 per minute (CPR Card: 83% vs control: 47%, p-value < 0.001).CPRcard group had a higher percentage of adequate compressions (CPRcard: 88% vs. no card: 46.8%, p-value = 0.037; CPRcard: 73% vs blinded card: 43%, p-value = 0.003).The participants in the CPRcard group more often performed better quality CPR, defined as simultaneously meeting targets for both compression rate of 100 to 120 and depth of at least 5cm (CPRcard: 36% vs control: 4%, p-value = 0.022). ConclusionsUse of the CPRcard by non-healthcare workers improved the quality of CPR chest compressions.

AIM:Differentiating between a newly deceased patient and the lifeless patient in whom immediate resuscitation is required may be facilitated by a pre-hospital anaesthesiologist. The purpose of our study was to investigate to what extent and why the pre-hospital anaesthesiologist pronounced life extinct in situations where an emergency medical technician (EMT) would have been required to resuscitate.METHODS:All lifeless patients seen pre-hospitally by the anaesthesiologist-manned Mobile Emergency Care Unit in Odense, Denmark, from 2010 to 2014 were retrospectively studied.RESULTS:Of 17 035 contacts, 1275 patients were lifeless without reliable signs of death. In 642 of these patients (3.8%) resuscitation was initiated (median age 68 years). The remaining 633 patients (3.7%) were declared dead at the scene without any resuscitation attempt (median age 77 years). These latter patients would have been attempted resuscitated, had the anaesthesiologist not been present. In 54.5% of cases where documentation was available in the patient records, reasons for not resuscitating these patients included time elapsed from incident to contact with physician, 'overall assessment', chronic disease, or do-not-resuscitate order.CONCLUSION:In one patient in 30, the MECU refrained from futile resuscitation in cases where legislation required an EMT to initiate resuscitation. This practice reduced unethical attempts of resuscitation, reduced unnecessary emergency ambulance transports, and reduced the work load of the hospital resuscitation teams for one unnecessary alarm every third day. Differentiating between lifeless patients and dead patients not exhibiting reliable signs of death, however, is a complex task which is only sparsely documented.

Brogaard's non-indexical version of moral contextualism has two related problems. It is unable to account for the function of truth-governed assertoric moral discourse, since it leaves two (semantically clearheaded) disputants without any incentive to resolve seemingly contradictory moral claims. The moral contextualist could explain why people do feel such an incentive by ascribing false beliefs about the semantic workings of their own language. But, secondly, this leaves Brogaard's moral contextualism looking weaker than a Mackie-style invariantist error theory about morals. The latter is equally non-objectivist, but less revisionist, since it takes the semantics of moral discourse at face value, and can also explain all of Brogaard's other linguistic evidence.

It has been suggested that the multicultural nature of modern liberal states (in particular the formation of immigration minorities from other cultures due to the process of globalisation) provides reasons -from a liberal egalitarian perspective -for recognising a civic or democratic norm, as opposed to a legal norm, that curbs exercises of the right to free speech that offend the feelings or beliefs of members from other cultural groups.The paper rejects the suggestion that acceptance of such a norm is in line with liberal egalitarian thinking.Following a review of the classical liberal egalitarian reasons for free speech -reasons from overall welfare, from autonomy and from respect for the equality of citizens -it is argued that these reasons outweigh the proposed reasons for curbing culturally offensive speech.Currently controversial cases such as that of the Danish Cartoon Controversy are used as illustrations.

It is common sense that things have properties. For instance, my chair has the property of being black, and blackness has the property of being a colour. Thus, on the face of it, we have to accept that there is a distinction between thingentities and property-entities. The classical view is that this everyday distinction reflects a more fundamental distinction in ontology between particulars and their properties. The questions whether we, in the final philosophical analysis, need such a distinction and, if we do, what particulars and properties are, are philosophical evergreens. An impressive succession of theories has appeared ever since Plato, but there is still no consensus in sight. This paper is, first of all, a survey of the debate over properties (and to a minor degree particulars). It is an attempt to map the field in a clear and systematic way and highlight the most important arguments for and against the central positions in the debate. 2 But, secondly, it is also an attempt to go some of the way towards identifying the most serious contenders for being the right theory of things and their properties. I shall be pointing to three theories that I believe are the main contenders for winning the prize with a summary of the most important pros and cons of each. These theories are Armstrong’s immanent or Aristotelian realism, Lewis’ modal class nominalism and Campbell’s moderate trope nominalism. Finally, it is an aim of the paper to discuss a meta-issue about the very status of the debate over properties in ontology. I give a short statement of what I take to be the most plausible methodology in ontology and I end up questioning whether there is any prospect of a final resolution of the debate. Is it realistic to aim for identifying a single true theory of properties? Or is it rather the case that the constraints on theorising in ontology are such that all we can plausibly hope for is to identify a set of good candidates with no prospect of reaching a determinate answer as to which is the best candidate – or the true theory? The structure of the paper is as follows. In section 1, I introduce the issues and main questions and give a brief overview of the theories to be examined. In section 2, I introduce the notion of a universal and discuss the varieties of realism and their commitments. Following the discussion in the section,