In the United States, more than 300,000 people annually experience cardiac arrest and undergo resuscitation attempts; of these, more than 200,000 are treated for in-hospital cardiac arrest. Because cardiac arrests often lead to premature death and/or morbidity, the American Heart Association (AHA) believes that incremental improvement in basic and advanced life support in the lay and medical communities will improve the survival rates of people experiencing cardiac arrests. That tenet is a laudable and important goal.(1,2,3)
Public health experts consider cardiopulmonary resuscitation (CPR) to be the most important and successful public health initiative today. Many people have prepared themselves through training in basic life support (BLS) and advanced cardiac life support (ACLS) to participate in the larger national ambition of preventing untimely deaths. Despite the enormous public health initiative, more than 50% of out-of-hospital resuscitation efforts do not succeed.(1,2,3)
Unfortunately, few ventricular arrest (VF) cardiac arrest patients admitted to emergency rooms and hospitals survive the arrest and ultimately go home, the corollary being that most CPR attempts will fail in terms of neurologically intact survival to hospital discharge. In 2020, bystander-witness VF arrest survival was dismal for any age. Survival to hospital discharge after EMS-treated cardiac arrest was 10.4%, and survival with good functional status was 8.2%.
The rates of survival to discharge, one-month survival, and one-year survival are increasing among out-of-hospital cardiac arrest patients who receive CPR, but the survival statistics are variable across different studies. Survival to hospital discharge after a non-traumatic, emergency medical services (EMS) treated cardiac arrest out of hospitals was only 12%. In the in-hospital setting, approximately 25% of cardiac arrest patients survive to hospital discharge. The numbers speak to the poor outcomes and the need to improve our approach to out-of-hospital and in-hospital sudden cardiac death.(1,2,3)
Successful resuscitation after cardiac arrest requires an integrated set of coordinated actions, including immediate recognition of cardiac arrest and activation of the emergency response team, early CPR with an emphasis on chest compressions that maintain brain and heart perfusion, early and rapid defibrillation, effective advanced life support measures, and integrated post-cardiac arrest care.
The potential for improved survival mandates increased participation and education by the lay community, primary providers, EMS, ED, code team, catheterization laboratory, and intensive care unit. The importance of this initiative to save human lives cannot be overstated.
Legal and Ethical Concerns: Good Samaritan Laws
Good Samaritan laws are designed to encourage individuals, including physicians, to render medical care gratuitously in emergency situations. Through these laws, physicians who act in good faith to render emergency care gratis are provided immunity from civil liability. Historically, such emergency care involved providing medical assistance to persons in emergencies in which bystanders were present, such as motor vehicle accidents.
Protection of physicians from allegations of negligence was meant to encourage active clinical participation, rather than cautious nonparticipation, in emergency care. In some states and under defined circumstances, the immunity may apply in the hospital setting as well as in the physician’s office.
Legislatures have continued to amend the statutes to expand the protection provided to physicians who offer emergency care. Judicial construction of the nature and scope of physician immunity has similarly grown.(4)
Providing basic life support is the right thing for a moral and ethical human being; citizen CPR responders have saved thousands of lives during the past three decades. Studies of layperson rescuers, automatic external defibrillators (AEDs) in airports and casinos, and first responder programs with police officers have shown excellent survival rates from out-of-hospital witnessed sudden cardiac arrest when there is bystander CPR and defibrillation within 3-5 minutes of collapse.(5)
The Good Samaritan Law is in place to protect a rescuer who has voluntarily helped a stranger in need from being sued for “wrongdoing.” In most of North America, there is no legal obligation to help a person in need, but since governments want to encourage people to help others, they pass Good Samaritan Laws. There are some stipulations with this law and specific guidelines that must be followed.(4)
First, if the patient is unconscious, consent is implied. If conscious, the patent must give permission to receive care. If the patient is an underage child in a life-threatening situation, and if the parent/guardian is nowhere to be found, consent is also implied. If the patient is of age and is conscious, however, their permission to help is required. If your efforts for help are refused, simply call 911 and the EMS will deal with the situation appropriately.
Second, you must be reasonably careful when aiding the victim, and you must not provide care beyond your skill level. For example, a person is choking, and you perform the Heimlich maneuver. If the airway remains obstructed and the person becomes unconscious, you begin CPR. This represents reasonable care.
Third, you act in “good faith” without any expectation of remuneration. Do not expect or accept any gratuities, no matter how small; this person owes you nothing. When you save a life, you do it out of the kindness of your heart, not for payment.
Fourth, if you do decide to help, always remember that once you start, you cannot stop unless someone with equal or higher emergency training takes over, the emergency services arrive, and you are in fear for your life (intense fatigue, lack of protective barrier devices, blood/other body fluids in area, danger/violence in area), or if the patient has a signed Do Not Resuscitate (DNR) card.
If you see a bright orange card that says DNR across the top, the words Do Not Resuscitate under them, and a signature of the victim and the victim’s physician under that, please stop. If you do not see a DNR card, DO NOT STOP.
Lastly, if you are a state-licensed healthcare provider, first responder, or other professional rescuer trained and expected to give emergency medical care, including CPR, you almost certainly have a duty to act. However, basic life support performed voluntarily on a stranger in need while off-duty is generally considered a Good Samaritan Act.
Existing Laws: Commonalities and Differences
Existing Good Samaritan laws share some parallels in coverage and intent, but there are differences. In the United States, each state has its own law. Some states have a Good Samaritan law that gives medical professionals and bystanders protection for a wide range of good faith rescue and assistance behaviors. In other states, the Good Samaritan laws are a collation of related laws, with each law protecting a subset of a particular profession or class of individuals.(4)
The type of action typically protected in Good Samaritan laws in the United Sates is reasonable behavior. Gross negligence, bad faith actions, reckless behavior, and behavior construed as an intention to injure are specifically excluded in existing Good Samaritan laws.(6) The activities covered by Good Samaritan laws in the United States vary from a narrow and specific list of first aid skills(7) to broad-spectrum classes of actions.(8)
States also vary as to the where protection is provided for bystander assistance, with assistance only being protected at the site of the accident(9) or at the scene of an emergency.(10) Only a minority of states provide immunity for assistance given during transit to the hospital.(11)
The variation in Good Samaritan laws has the potential to affect provider willingness to participate in bystander life support.
The existing United States laws are inconsistent as to who is protected by Good Samaritan laws. Two classes of protected individuals emerge: medical professionals and trained non-medical professionals. Each potentially protected group is critical to the chain of survival of victims of sudden death, as outlined by the AHA. Medical professionals can theoretically provide the victim a higher level of care than the trained, or untrained non-medical bystander.
Unfortunately, the likelihood of a medical professional being at the scene of an out-of-hospital cardiac arrest is unlikely. The non-medical bystander is crucial in the chain of survival outlined by the AHA. The importance of bystander action mandates a need for complete immunity from legal recourse if the bystander acted in good faith. Additionally, it raises the important issue of improving the availability of BLS courses to all individuals in our communities.
A Model Good Samaritan Law
It is possible to develop a “model” Good Samaritan Law that protects voluntary responders rendering aid in an emergency. To ensure that bystanders feel comfortable to render aid to victims of illness or injury, the laws must be clear and concise to avoid confusion that would deter them from offering potentially lifesaving assistance. It will require a broad range of activities and locations that will and must be protected.
Protection for bystanders should include individuals with formal training and those with no formal training in first aid and BLS. This proposal is motivated by two factors:
Bystanders with formal training may not know if their training qualifies for immunity under the existing state law, and they may be hesitant to help if they believe they might be exposed to liability.
Even untrained bystanders may be able to provide life-saving assistance, from instinct or intuition. Good Samaritan laws should have a scope beyond medical assistance to include such acts as transporting the patient to a hospital or removing them from a dangerous situation, such as a burning vehicle.
Reasonable behavior is conduct that a person of similar experience and ability would display in the same or similar circumstances. Good Samaritan laws protect those who act in good faith and whose actions are reasonable. The laws do not protect responders who act in bad faith, in a grossly negligent manner, or who willfully disregard the safety of the person they are trying to help.
The Law Commission Report on the Civil Liability of Good Samaritans and Responders suggests several factors a court should consider when determining if a responder’s behavior is reasonable. These factors include the probability that the accident was caused by the responder’s behavior, the gravity of the threatened injury, the cost of eliminating the risk, and the social utility of the responder’s conduct.(12) The last factor refers not only to the reasonableness of the action in the particular situation, but also to the overall benefit to society.
Conclusion
An effective Good Samaritan law must be clear, concise, and easy to understand; provide protection for trained and untrained bystanders; and cover medical assistance and transportation to a higher level of medical care. In addition, it must provide some legal recourse for those who are injured by those acting in bad faith or with reckless, negligent purpose.
These standards will encourage professionals and bystanders to provide assistance in medically emergent situations without fear of liability. This type of legal immunity for acting in a good faith, reasonable manner will save the lives of victims of life-threatening events.
Physicians must be proactive in encouraging the implementation of Good Samaritan laws that protect all providers acting in good faith, showing lawmakers the impact provider immunity will have on our goal to prevent sudden cardiac death. Additionally, physicians must encourage all citizens to learn basic life support. Life is why.
References
Merchant RA, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, Lavonas EJ, Magid DJ.Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. On behalf of the Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups. Circulation. 2020;142(16)suppl_2.
CDC, NCHS. Underlying Cause of Death 1999-2013 on CDC Wonder Online Database, release 2015. Data are from the Multiple Cause of Death Files. Accessed August 15, 2017.
Mozaflarian D, Benjamin EJ, Go AS, et al., Heart Disease and Stroke Statistics – 2015 Update: A Report from the American Heart Association. Circulation. 2015;131:e29-322.
Paterick T, Paterick B, Paterick T. Implications of Good Samaritan Laws for Physicians. J Med Pract Manage. 2008;23(6):372–375.
Terence D. Valenzuela, MD, MPH, Denise J Roe, Dr.PH, Graham Nichol, MD, MPH. Outcomes of Rapid Defibrillation by Security Officers After Cardiac Arrest in Casinos. NEJM. 2000;343:1206–1209.
Ind. Code Ann & 34-30-12 -1(b)
Okla. Stat. tits. 76, 5(a)(2)
Md. Code Ann. Cts. & Jud. Proc. 5-603(a)
745 111 Comp Stat 49/1-75
Utah Code Ann. 78-11-22 (1)
Wash. Rev. Code & 4.24.300.
Law Reform Commission. Civil Liability of Good Samaritans and Volunteers. Dublin: Law Reform Commission;2009.