title: Ethically justified treatment limitations in emergency situations.
abstract: OBJECTIVE
  Medical emergency teams (METs) implement do not attempt cardiopulmonary resuscitation (DNACPR) orders and other limitations of medical treatment (LOMTs) in hospitals regularly. However, METs operate in emergency situations with limited or no patient information at the scene. We aimed to study the medical ethics of LOMTs implemented in in-hospital emergency situations.
  
  
  METHODS
  This was a prospective observational study with retrospect case-note analysis conducted in a single Finnish university hospital over 16 months. Data were collected according to the Utstein-style scientific statement.
  
  
  RESULTS
  There were 774 reviews on 640 patients without preceding LOMT. During the reviews MET assigned LOMTs (including 55 DNACPR orders) for a group of 59 patients who were older (median 77 vs. 68 years; P<0.001) and had higher cumulative comorbidity (median Charlson comorbidity index 2 vs. 1; P=0.001) compared with patients without LOMTs (no-LOMT). Most reviews (71%) leading to new LOMTs occurred during on-call time. In the majority of LOMT cases at least two physicians (86%) and the patient/relatives (76%) were involved in the decision-making. All but one (98%) of the LOMT reviews were documented in the electronic patient records and included clearly described rationale for the LOMT. The median durations of the MET reviews (31 vs. 31 min, P=0.9) were comparable in the two groups. Age alone was never recorded as a reason for LOMT.
  
  
  CONCLUSIONS
  LOMTs were implemented in a decent and ethically justified manner in emergency situations following the code of conduct recommended by guidelines, even though MET operated under highly suboptimal circumstances for end-of-life care planning.
authors.affiliation: aDepartment of Intensive Care Medicine and Critical Care Medicine Research Group, Tampere University Hospital, Tampere bDepartment of Anaesthesiology, Seinäjoki Central Hospital, Seinäjoki cDepartment of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland dDepartment of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden.
authors.forename: Joonas
authors.initials: J
authors.lastname: Tirkkonen
authors.forename: Klaus T
authors.initials: KT
authors.lastname: Olkkola
authors.forename: Jyrki
authors.initials: J
authors.lastname: Tenhunen
authors.forename: Sanna
authors.initials: S
authors.lastname: Hoppu
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation / Q000941:ethics / Q000706:statistics & numerical data; D004630:Emergencies; D004632:Emergency Medical Services / Q000941:ethics; D005260:Female; D005387:Finland; D006785:Hospitals, University / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016414:Resuscitation Orders / Q000941:ethics*; D028761:Withholding Treatment / Q000941:ethics*