Joshi (2015)  prospectively investigated cardiopulmonary resuscitation (CPR) in an Indian hospital scenario. However, the paper did not provide the reasons why 153 out of 413 in-hospital “witnessed” arrests were not considered for resuscitation attempts (the numbers, who did not qualify for CPR after in-hospital arrest, seem quite significant). If this data is assumed generalizable to the in-hospital population in India, it may seem that 37% of all in-hospital arrests in India may not qualify (and hence may NOT be considered) as candidates for CPR. This may reflect the ethical dilemmas of the Indian hospitals when dealing with the problematic clinical scenarios requiring CPR and emergency cardiovascular care (ECC). Primarily, this may be secondary to the absence of legal guidelines (local or national) about the advance directives for do-not-attempt-resuscitation (DNAR) despite the position statements (2014) by the Indian Society of Critical Care Medicine (ISCCM)  and the Indian Association of Palliative Care (IAPC) . Nevertheless, it is my humble understanding that Joshi (2015)  should provide the explanations: (a) Were 153 patients excluded according to the study’s exclusion criteria? Excluded patients’ distribution among the corresponding exclusion criteria would be helpful; and if NOT then, (b) Were the patients’ surrogates included in the decision-making at the critical time of “witnessed” arrests? The CPR-withheld patients’ distribution among the corresponding reasons for not-resuscitating would be helpful. The American Heart Association (AHA)  addresses the CPR/ECC ethics by preferring withdrawal of life-support (after attempting CPR) over withholding CPR (when “witnessing” cardiac arrests). Unless there are DNAR orders in-situ, or patients dead irreversibly (clinically), or risks of physical injury to the CPR performers, CPR should be attempted. However, per the AHA 2000 guidelines , it seems ethical to withheld CPR in the non-viable newborns, and the deteriorating patients going into cardiac arrest in spite of their maximal and exhaustive in-hospital treatments. In summary, it is my humble reiteration that Joshi (2015)  should publish erratum as to why 153 patients out of 413 in-hospital “witnessed” arrests were not considered for CPR.
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4. [No authors listed]. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part2: ethical aspects of CPR and ECC. Circulation 2000;102(8 Suppl):I12-21. Available at: http://circ.ahajournals.org/content/102/suppl_1/I-12.long Last Accessed on February 08, 2017.
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