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Resuscitation. 2016 Mar;100:11-7. doi: 10.1016/j.resuscitation.2015.12.010. Epub 2016 Jan 14.

A survey of key opinion leaders on ethical resuscitation practices in 31 European Countries.

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University of Athens Medical School, Athens, Greece. Electronic address:
University of Antwerp, Antwerp, Belgium.
Municipal Institute for Emergency Medicine Novi Sad, Novi Sad, Serbia.
Medical School, University of Crete, Heraklion, Greece; Ethics Committee of the European Society for Emergency Medicine (EuSEM), London, UK.
Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK.
University Hospital Bern and University of Bern, Bern, Switzerland.
Royal College of Nursing Research Institute, Warwick Medical School, University of Warwick, Coventry, UK.
University Hospital and University Ghent, Ghent, Belgium; Federal Department Health, Ghent, Belgium.
University of Athens, Medical School, Athens, Greece; Midwestern University, Chicago, IL, USA.



Europe is a patchwork of 47 countries with legal, cultural, religious, and economic differences. A prior study suggested variation in ethical resuscitation/end-of-life practices across Europe. This study aimed to determine whether this variation has evolved, and whether the application of ethical practices is associated with emergency care organisation.


A questionnaire covering four domains of resuscitation ethics was developed based on consensus: (A) Approaches to end-of-life care and family presence during cardiopulmonary resuscitation; (B) Determinants of access to best resuscitation and post-resuscitation care; (C) Diagnosis of death and organ donation (D) Emergency care organisation. The questionnaire was sent to representatives of 32 countries. Responses to 4-choice or 2-choice questions pertained to local legislation and common practice. Positive responses were graded by 1 and negative responses by 0; grades were reconfirmed/corrected by respondents from 31/32 countries (97%). For each resuscitation/end-of-life practice a subcomponent score was calculated by grades' summation. Subcomponent scores' summation resulted in domain total scores.


Data from 31 countries were analysed. Domains A, B, and D total scores exhibited substantial variation (respective total score ranges, 1-41, 0-19 and 9-32), suggesting variable interpretation and application of bioethical principles, and particularly of autonomy. Linear regression revealed a significant association between domain A and D total scores (adjusted r(2)=0.42, P<0.001).


According to key experts, ethical practices and emergency care still vary across Europe. There is need for harmonised legislation, and improved, education-based interpretation/application of bioethical principles. Better application of ethical practices may be associated with improved emergency care organisation.


Bioethics; Cardiac arrest; Emergency care; End of life care; Resuscitation

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