Life support

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Life support
Endotracheal tube of an emergency ventilator system
Specialty emergency medicine

Life support refers to the treatments and techniques performed in an emergency in order to support life after the failure of one or more vital organs. Healthcare providers and emergency medical technicians are generally certified to perform basic and advanced life support procedures; however, basic life support is sometimes provided at the scene of an emergency by family members or bystanders before emergency services arrive. In the case of cardiac injuries, cardiopulmonary resuscitation is initiated by bystanders or family members 25% of the time. Basic life support techniques, such as performing CPR on a victim of cardiac arrest, can double or even triple that patient's chance of survival. [1] Other types of basic life support include relief from choking (which can be done by using the Heimlich maneuver), staunching of bleeding by direct compression and elevation above the heart (and if necessary, pressure on arterial pressure points and the use of a manufactured or improvised tourniquet), first aid, and the use of an automated external defibrillator.


The purpose of basic life support (abbreviated BLS) is to save lives in a variety of different situations that require immediate attention. These situations can include, but are not limited to, cardiac arrest, stroke, drowning, choking, accidental injuries, violence, severe allergic reactions, burns, hypothermia, birth complications, drug addiction, and alcohol intoxication. The most common emergency that requires BLS is cerebral hypoxia, a shortage of oxygen to the brain due to heart or respiratory failure. A victim of cerebral hypoxia may die within 8–10 minutes without basic life support procedures. BLS is the lowest level of emergency care, followed by advanced life support and critical care. [2]


As technology continues to advance within the medical field, so do the options available for healthcare. Out of respect for the patient's autonomy, patients and their families are able to make their own decisions about life-sustaining treatment or whether to hasten death. [3] When patients and their families are forced to make decisions concerning life support as a form of end-of-life or emergency treatment, ethical dilemmas often arise. When a patient is terminally ill or seriously injured, medical interventions can save or prolong the life of the patient. Because such treatment is available, families are often faced with the moral question of whether or not to treat the patient. Much of the struggle concerns the ethics of letting someone die when they can be kept alive versus keeping someone alive, possibly without their consent. [4] Between 60 and 70% of seriously ill patients will not be able to decide for themselves whether or not they want to limit treatments, including life support measures. This leaves these difficult decisions up to loved ones and family members.

Patients and family members who wish to limit the treatment provided to the patient may complete a do not resuscitate (DNR) or do not intubate (DNI) order with their doctor. These orders state that the patient does not wish to receive these forms of life support. Generally, DNRs and DNIs are justified for patients who might not benefit from CPR, who would result in permanent damage from CPR or patients who have a poor quality of life prior to CPR or intubation and do not wish to prolong the dying process.

Another type of life support that presents ethical arguments is the placement of a feeding tube. Decisions about hydration and nutrition are generally the most ethically challenging when it comes to end-of-life care. In 1990, the US Supreme Court ruled that artificial nutrition and hydration are not different from other life-supporting treatments. Because of this, artificial nutrition and hydration can be refused by a patient or their family. A person cannot live without food and water, and because of this, it has been argued that withholding food and water is similar to the act of killing the patient or even allowing the person to die. [5] This type of voluntary death is referred to as passive euthanasia. [6]

In addition to patients and their families, doctors also are confronted with ethical questions. In addition to patient life, doctors have to consider medical resource allocations. They have to decide whether one patient is a worthwhile investment of limited resources versus another. [7] Current ethical guidelines are vague since they center on moral issues of ending medical care but disregard discrepancies between those who understand possible treatments and how the patient's wishes are understood and integrated into the final decision. Physicians often ignore treatments they deem ineffective, causing them to make more decisions without consulting the patient or representatives. However, when they decide against medical treatment, they must keep the patient or representatives informed even if they discourage continued life support. Whether the physician decides to continue to terminate life support therapy depends on their own ethical beliefs. These beliefs concern the patient's independence, consent, and the efficacy and value of continued life support. [8] In a prospective study conducted by T J Predergast and J M Luce from 1987 to 1993, when physicians recommended withholding or withdrawing life support, 90% of the patients agreed to the suggestion and only 4% refused. When the patient disagreed with the physician, the doctor complied and continued support with one exception. If the doctor believed the patient was hopelessly ill, they did not fulfill the surrogate's request for resuscitation. [9] In a survey conducted by Jean-Louis Vincent MD, PhD in 1999, it was found that of European intensivists working in the Intensive Care Unit, 93% of physicians occasionally withhold treatment from those they considered hopeless. Withdrawal of treatment was less common. For these patients, 40% of the physicians gave large doses of drugs until the patient died. All of the physicians were members of the European Society of Intensive Care Medicine. [10]

Case studies

Sawatzky vs. Riverview Health Center Inc., November 1998

Mr. Sawatsky had Parkinson's disease and had been a patient at the Riverview Health Centre Inc. since May 28, 1998. When he was admitted to the hospital, the attending physician decided that if he went into cardiac arrest, he should not be resuscitated. Mrs. Sawatsky opposed the decision and the doctor complied. Later, the doctor decided that the patient needed a cuffed tracheostomy tube, which Mrs. Sawatsky opposed. In response, the hospital applied to have a Public Trustee become the patient's legal guardian and the Trustee consented to the operation. In late October, without consulting another physician or the patient's wife, the physician again made a "do not resuscitate" order after the patient developed pneumonia. Mrs. Sawatzky went to court for an interim order to remove the DNR. The "do not resuscitate" order was withdrawn.

In the case law to date in 1988, the courts decided that a decision to withhold or withdraw treatment was only for the physician to make, not the courts. However, the Manitoba court decided that given the scarcity of related cases and how none of them considered the Charter of Rights and Freedoms, it would try the case. Previous courts had held that physicians should not be bound by law to provide treatment that they didn't believe the patient would want. Otherwise, the physician would be acting against his conscience and his duty as a physician. However, if the patient disagreed, they can sue the physician for negligence. To avoid this, Justice Beard ruled in favor of the patient. Resuscitation is not controversial and only requires CPR, which would be performed by the first qualified person on the scene. Even if resuscitation was an ethical dilemma, it was minor given that the doctor had allowed resuscitation for several months already. In contrast with related cases in which patients were comatose, Mrs. Sawatzky provided evidence that her husband was able to communicate and believed that he could recover, but the doctor disagreed. The uncertainty of recovery pushed the Court to order the physician to allow resuscitation. Where rulings discuss end of life issues, the question is more, "Is continued life a benefit to this person" instead of, "Is it possible to treat this person". These questions are beyond the scope of the medical profession and can be answered philosophically or religiously, which is also what builds our sense of justice. Both philosophy and religion value life as a basic right for humans and not as the ability to contribute to society and purposely encompasses all people. Mr. Sawatzky fell under the umbrella, so the judge ruled in his favor. [11]

Airedale NHS Trust v. Bland (1993)

The Airedale NHS Trust v. Bland case was an English House of Lords decision for a 17-year-old comatose survivor of the Hillsborough disaster. He had been artificially fed and hydrated via life support for about 3 years. However, he had not shown any improvement while in his persistent vegetative state. His parents challenged the therapeutic life support at the High Court and wanted permission to end life support for their son. The Court decided that his "existence in a persistent vegetative state is not a benefit to the patient," but the statement didn't cover the innate value of human life. The court interpreted the sanctity of life as only applicable when life could continue in the way that the patient would have wanted to live their life. If the quality of life did not fall within what the patient valued as a meaningful life, then sanctity of life did not apply. The accuracy of a proxy's decision about how to treat a patient is influenced by what the patient would have wanted for themselves. However, just because the patient wanted to die did not mean the courts would allow physicians to assist and medically kill a patient. This part of the decision was influenced by the case Rodriguez (1993) in which a British Columbian woman with amyotrophic lateral sclerosis could not secure permission for assisted suicide. [12]


There are many therapies and techniques that may be used by clinicians to achieve the goal of sustaining life. Some examples include:

These techniques are applied most commonly in the Emergency Department, Intensive Care Unit and Operating Rooms. As various life support technologies have improved and evolved they are used increasingly outside of the hospital environment. For example, a patient who requires a ventilator for survival is commonly discharged home with these devices. Another example includes the now-ubiquitous presence of automated external defibrillators in public venues which allow lay people to deliver life support in a prehospital environment.

The ultimate goals of life support depend on the specific patient situation. Typically, life support is used to sustain life while the underlying injury or illness is being treated or evaluated for prognosis. Life support techniques may also be used indefinitely if the underlying medical condition cannot be corrected, but a reasonable quality of life can still be expected.

See also

Related Research Articles

Emergency medical services Emergency services dedicated to providing out-of-hospital acute medical care and transport to definitive care

Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. They may also be known as a first aid squad, FAST squad, emergency squad, ambulance squad, ambulance corps, life squad or by other initialisms such as EMAS or EMARS.

Clinical death is the medical term for cessation of blood circulation and breathing, the two criteria necessary to sustain the lives of human beings and of many other organisms. It occurs when the heart stops beating in a regular rhythm, a condition called cardiac arrest. The term is also sometimes used in resuscitation research.

A medical emergency is an acute injury or illness that poses an immediate risk to a person's life or long-term health, sometimes referred to as a situation risking "life or limb". These emergencies may require assistance from another, qualified person, as some of these emergencies, such as cardiovascular (heart), respiratory, and gastrointestinal cannot be dealt with by the victim themselves. Dependent on the severity of the emergency, and the quality of any treatment given, it may require the involvement of multiple levels of care, from first aiders through emergency medical technicians, paramedics, emergency physicians and anesthesiologists.

Advanced cardiac life support

Advanced cardiac life support, or advanced cardiovascular life support, often referred to by its acronym, "ACLS", refers to a set of clinical algorithms for the urgent treatment of cardiac arrest, stroke, myocardial infarction, and other life-threatening cardiovascular emergencies. Outside North America, Advanced Life Support (ALS) is used.

Do not resuscitate

A do-not-resuscitate order (DNR), also known as no code or allow natural death, is a legal order, written or oral depending on country, indicating that a person does not want to receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes it also prevents other medical interventions. The legal status and processes surrounding DNR orders vary from country to country. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient wishes and values.

Medical ethics System of moral principles of the practice of medicine

Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. These values include the respect for autonomy, non-maleficence, beneficence, and justice. Such tenets may allow doctors, care providers, and families to create a treatment plan and work towards the same common goal. It is important to note that these four values are not ranked in order of importance or relevance and that they all encompass values pertaining to medical ethics. However, a conflict may arise leading to the need for hierarchy in an ethical system, such that some moral elements overrule others with the purpose of applying the best moral judgement to a difficult medical situation. Medical ethics is particularly relevant in decisions regarding involuntary treatment and involuntary commitment.

Prior to the introduction of brain death into law in the mid to late 1970s, all organ transplants from cadaveric donors came from non-heart-beating donors (NHBDs).

Basic life support (BLS) is a level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital. It can be provided by trained medical personnel, such as emergency medical technicians, and by qualified bystanders.

The Seattle & King County Emergency Medical Services System is a fire-based two-tier response system providing prehospital basic and advanced life support services.

Stephanie Keene, better known by the pseudonym Baby K, was an anencephalic baby who became the center of a major American court case and a debate among bioethicists.

Futile medical care is the continued provision of medical care or treatment to a patient when there is no reasonable hope of a cure or benefit.

Advanced life support Life-saving protocols

The Advanced Life Support ( ) is a set of life saving protocols and skills that extend basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing).

ABC (medicine)

ABC and its variations are initialism mnemonics for essential steps used by both medical professionals and lay persons when dealing with a patient. In its original form it stands for Airway, Breathing, and Circulation. The protocol was originally developed as a memory aid for rescuers performing cardiopulmonary resuscitation, and the most widely known use of the initialism is in the care of the unconscious or unresponsive patient, although it is also used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations, from first-aid to hospital medical treatment. Airway, breathing, and circulation are all vital for life, and each is required, in that order, for the next to be effective. Since its development, the mnemonic has been extended and modified to fit the different areas in which it is used, with different versions changing the meaning of letters or adding other letters.

Cardiopulmonary resuscitation, also known by the acronym CPR, is an emergency procedure performed in an effort to manually preserve intact brain function by maintaining adequate perfusion of tissue until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. CPR is a fundamental component of first aid that is practiced across the world. It is an effective method of keeping a victim of cardiac arrest alive long enough for definitive treatment to be delivered, usually through defibrillation and administration of intravenous drugs such as epinephrine and amiodarone.

Euthanasia is illegal in most of the United States. Assisted suicide/assisted death is legal in Washington, D.C. and the states of California, Colorado, Oregon, Vermont, Maine, New Jersey, Hawaii, and Washington; its status is disputed in Montana, though currently authorized per the Montana Supreme Court's ruling in Baxter v. Montana that "nothing in Montana Supreme Court precedent or Montana statutes [indicates] that physician aid in dying is against public policy."

Lazarus syndrome, also known as autoresuscitation after failed cardiopulmonary resuscitation, is the spontaneous return of a normal cardiac rhythm after failed attempts at resuscitation. Its occurrence has been noted in medical literature at least 38 times since 1982. It takes its name from Lazarus who, as described in the New Testament, was raised from the dead by Jesus.

Child euthanasia is a form of euthanasia that is applied to children who are gravely ill or suffer from significant birth defects. In 2005, the Netherlands became the first country to decriminalize euthanasia for infants with hopeless prognosis and intractable pain. Nine years later, Belgium amended its 2002 Euthanasia Act to extend the rights of euthanasia to minors. Like euthanasia, there is world-wide public controversy and ethical debate over the moral, philosophical and religious issues of child euthanasia.

POLST is an approach to improving end-of-life care in the United States, encouraging providers to speak with the severely ill and create specific medical orders to be honored by health care workers during a medical crisis. POLST began in Oregon in 1991 and currently exists in 46 states; some of the 46 states have the program in development. The POLST document is a standardized, portable, brightly colored single page medical order that documents a conversation between a provider and an individual with a serious illness or frailty towards the end of life. A POLST form allows emergency medical services to provide treatment that the individual prefers before possibly transporting to an emergency facility.

Slow code refers to the practice in a hospital or other medical centre to purposely respond slowly or incompletely to a patient in cardiac arrest, particularly in situations for which cardiopulmonary resuscitation (CPR) is of no medical benefit. The related term show code refers to the practice of a medical response that is medically futile, but is attempted for the benefit of the patient's family and loved ones. However, the terms are often used interchangeably.

Emergency medical services in Russia is a type of medical assistance provided to citizens in cases of accident, illnesses, injuries, poisonings, and other conditions requiring urgent medical intervention. These services are typically provided by a city or regional government, public emergency hospital, or the Disaster Medical Service. The emergency number for dialing an ambulance in Russia is 03 or the generic European 112.


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