[Palliative extubation after ROSC in the emergency setting-a guideline for emergency physicians]

In the prehospital emergency setting, resuscitation following cardiac arrest is initiated as soon as possible after arrival of the emergency services in order to minimize the no-flow time, i.e., the period during which there is no blood circulation and therefore no oxygen supply to the organs. There is frequently no opportunity to ask relatives about the prespecified or presumed wishes of the patient, e.g., in the form of a living will, until after initiation of emergency medical interventions. If an advance directive stipulates "do not resuscitate" (DNR), then this wish is legally binding for treatment. However, if return of spontaneous circulation (ROSC) has been achieved in the meantime, the treating emergency team faces an ethical dilemma, and patients are often taken to hospital against their prespecified will. This leads to unwanted overtreatment. Based on three case reports, the following article discusses the ethical and legal aspects of palliative extubation after ROSC in patients with a predefined DNR status.