Do Not Resuscitate Orders: When hospital CPR should not be used

(GETTY IMAGES)

The issue of resuscitation was recently brought to the fore, following the case of a man with Down’s Syndrome, who was issued with a Do Not Resuscitate order without consent from either himself or his family. His family is now taking legal action against the hospital on his behalf.

The case throws up some interesting questions, particularly the circumstances under which a do not resuscitate decision might be considered. Resuscitation, or more precisely, cardiopulmonary resuscitation (CPR) is the process of trying to restart the heart after it has stopped. CPR is a highly invasive medical intervention, which includes chest compressions, defibrillation (electric shocks), injection of potent drugs into the circulation, and artificial ventilation.

Each year in the UK, approximately 30,000 patients receive CPR in hospital. The reality of survival rates in today’s world is substantially different from early reports with only one to two people surviving for every 10 receiving CPR. Certain factors are known to influence the outcome. For example, a witnessed cardiac arrest, that occurs secondary to an acute cardiac problem, have good outcomes with survival around 40%. By contrast CPR in the very frail, or in patients with an acute stroke, severe injury, severe infection, cancer, liver or renal failure, or homebound lifestyle are associated with poor survival.

Applying CPR in circumstances where the chances of success are negligible, denies the patient the opportunity of a dignified death. Do not attempt cardiopulmonary resuscitation decisions (DNACPR) or DNAR (do not attempt resuscitation) are written instructions to withhold CPR in the event of a cardiac arrest. They apply only to the decision about whether to start CPR or not if a patient sustains a cardiac arrest. They do not limit the provision of other treatments or nursing care.

In the UK, national guidance on the use of DNACPR decisions is provided in two documents: “Decisions relating to Cardiopulmonary Resuscitation”, produced by the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing and from the General Medical Council’s publication “Treatment and care towards the end of life: good practice in decision making”.

These guidelines identify three situations during which withholding CPR may be legally and ethically justifiable. Firstly, when a patient has made an advanced decision (“living will”) or makes an informed decision to refuse CPR. Secondly, when clinical judgment concludes that CPR will not be successful in restarting the patient’s heart and breathing and restoring circulation, for example if a patient is dying from another other irreversible condition. Thirdly, when following careful discussion with the patient and/or those close to them, an agreement is reached that the benefits of CPR are outweighed by the burdens and risks.

The guidelines emphasize the importance of communication. Doctors and nurses can’t be forced to provide a treatment that they know will not work. In most situations, the doctors will inform patients of a DNACPR decision. Some patients do not want to talk about things like DNACPR as they find it distressing. In this situation, the doctor will usually seek permission to inform those close to the patient, although not all patients agree to this. Where there is conflict or disagreement about a DNACPR decision, seeking a second opinion from another doctor can often be helpful.

Where there is uncertainty about the likelihood of success, or where the decision is based on a balance of the benefits and burdens of CPR, the options available should be discussed with patients, and with the patient’s consent their relatives, as part of their overall treatment plan. If the patient is unable to make decisions for themselves, for example, someone who is unconscious or has impaired functioning of the mind, the Mental Capacity Act (2005) mandates clinical staff to talk to people close to the patient. This might be a relative, friend or someone with a lasting power of attorney or nominated by the court, or an Independent Mental Capacity Advocate. The purpose of these discussions is to try to find out what the patient would have wanted, if they were in a position to communicate a decision for themselves. The doctor must consider these views when making a decision on behalf of the patient.

There have been a number of calls for a national policy relating to CPR, in the belief that this will be a solution to the problems reported in the press. I am not so certain that this will change things very much. There is already national guidance about DNACPR decisions that is widely implemented across NHS Trusts. I believe we need to look deeper than this, to get a better understanding of why current policies might not be working. This work should involve patients, their families and healthcare professionals, so that together a way forward is found to ensure CPR is delivered promptly. But at the same time, ensuring that a process exists to allow those reaching the end of their natural lives to die with dignity and without the trauma of a failed resuscitation attempt.

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• http://twitter.com/iHealthP iHealth

  Sorry, but this article is wrong and misleading. CPR is highly unlikely to restart a heart. The process of chest compressions (the “C” bit of CPR) is intended to keep blood flowing round the body until it either spontaneously restarts or receives successful defibrillation. CPR does NOT include injections of any drugs (typically adrenaline), nor does it include defibrillation. The “P” bit of CPR is artificial respiration, or what used to be called the “kiss of life”. The objective of CPR is to delay tissue death and thus extend the time during which other resuscitation methods can be used without incurring permanent brain damage,

  Resuscitation is not the same as CPR.

• Doc

  Actually iHealth, you’re wrong. As a doctor I can tell you that from a hospital PoV we mean exactly what Gavin describes. Furthermore, as a man heavily involved with the ERC and medical student teaching, he’s in a pretty good place to describe it. Your comment serves to highlight that patients don’t always understand what we mean.

• Halfassedmonkeyboy

  Then why does the “R” in CPR stand for resuscitation? Have you ever performed CPR?
  Outside of a hospital environment or absent prompt professional medical attention then I see your point, the kiss of life and chest compressions do serve to delay tissue death, but they are unlikely to restart a heart without the drugs or defibrillation. In a hospital or properly equipped ambulance then you have a chance but it’s not always a good chance.

• http://twitter.com/iHealthP iHealth

  When talking to the general public, it is sensible to talk in terms that the general public will understand. It is fine writing as if you were doing so for a roomfull of Med students. It is another to do so for a national newspaper. Boy Scouts and airline cabin crew are qualified to do CPR (i.e. compressions & artificial respiration). They are very far from qualified to inject or to use defibrillators.

  My point (probably badly expressed) is that there is a distinction between Resuscitiation from the PoV of a patient’s notes and what 99% of the general public think of when hearing the term CPR. This is why I called the article misleading.

  Your rather patronising point also highlights that clinicians generally need to think about the words and terms they use and ask themselves whether they are likely to be understood by the people to whom they are speaking. Communication (or rather, the lack of it) is very often at the bottom of misunderstandings between a patient, the patient’s relatives and those responsible for the patient’s care. A gap caused by poor communication might often be where unauthorised DNR orders emerge.

  Whatever the definition one uses, whoever is responsible for putting such an order on a patient’s notes should NEVER do so without prior consultation with relatives. Making such a judgement without either agreement, consultation, or knowledge is dangerously close to criminal.

• http://twitter.com/iHealthP iHealth

  Yes, I have performed CPR. My point is that “Resuscitation” is not the same as “CPR” as implied by the article – “Resuscitation” includes “CPR” but is not limited to that.