My opinion

By Dr. Deepak Gupta
Corresponding Author Dr. Deepak Gupta
Wayne State University, - United States of America 48201
Submitting Author Dr. Deepak Gupta

Cardiopulmonary-Resuscitation, India, Do-Not-Attempt-Resuscitation, Indian-Society-of-Critical-Care-Medicine, Indian-Association-of-Palliative-Care, Advance-Directives

Gupta D. To be, or Not to be - Apt William Shakespeare HAMLET Words Define Cardiopulmonary Resuscitation - CPR - Scenarios in India. WebmedCentral CARDIOLOGY 2017;8(2):WMC005254

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 14 Feb 2017 01:24:41 PM GMT
Published on: 14 Feb 2017 01:27:47 PM GMT

My Opinion

Joshi (2015) [1] 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) [2] and the Indian Association of Palliative Care (IAPC) [3]. Nevertheless, it is my humble understanding that Joshi (2015) [1] 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) [4] 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 [4], 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) [1] should publish erratum as to why 153 patients out of 413 in-hospital “witnessed” arrests were not considered for CPR.


1. Joshi M. A prospective study to determine the circumstances, incidence and outcome of cardiopulmonary resuscitation in a referral hospital in India, in relation to various factors. Indian J Anaesth 2015;59:31-6. Available at: Last Accessed on February 08, 2017.
2. Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, Kulkarni P, Simha S, Mani RK. End-of-life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med 2014;18:615-35. Available at: Last Accessed on February 08, 2017.
3. Macaden SC, Salins N, Muckaden M, Kulkarni P, Joad A, Nirabhawane V, Simha S. End of life care policy for the dying: consensus position statement of Indian association of palliative care. Indian J Palliat Care 2014;20:171-81. Available at: Last Accessed on February 08, 2017.
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: Last Accessed on February 08, 2017.

Source(s) of Funding


Competing Interests


0 reviews posted so far

0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.


Author Comments
0 comments posted so far


What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)