Decisions relating to CPR
A joint statement by the BMA, RC(UK) & RCN
David Pitcher
Consultant Cardiologist, University Hospital Birmingham Chairman, Resuscitation Council (UK)
Conflicts of interest
• Contributor on behalf of RC(UK) to “Decisions relating to cardiopulmonary resuscitation”
• Member of expert group for NCEPOD study on cardiac arrest
A journey
CPR decisions
• How did we get here?
• Where are we?
Julian DG
Treatment of cardiac arrest in acute myocardial ischaemia and infarction
Lancet 1961;ii:840-844
CORONARY CARE UNITS
Killip T, Kimball JT
Treatment of myocardial infarction in a coronary care unit: a two-year experience with 250 patients
Younger, fitter patients
admitted to CCU
...but...
•
Natural history of AMI changed:
fewer STEMI, fewer VF arrests
•
Many more patients admitted to CCU
with multiple medical problems
and limited life expectancy
...and...
•
CPR still used in other settings
•
Huge increase in admissions
•
Older, sicker patients
CPR not appropriate for all
Decisions about CPR
…….DNR
…….No code
…….DNAR
…….DNACPR
The year 2000
The Human Rights Act 1998
became law
April 2000
Cancer patient's fury at doctor who 'wrote her off on hospital's death ward' The Guardian
Thursday 13 April 2000
Secret 'not for resuscitation' code on pensioner's notes
By Jeremy Laurance, Health Editor
The year 2007
Problems reported with
Joint Statement 2001
Decisions relating to
cardiopulmonary resuscitation
2001
“…decisions about whether the likely benefits from successful CPR outweigh burdens should be
discussed with competent patients.
…where patients are at foreseeable risk of cardiac arrest, or have a terminal illness, there should be a
sensitive exploration of their wishes regarding resuscitation”
Misinterpreted by some healthcare
professionals as indicating:
• compulsion to discuss CPR with all patients
• requirement for “consent” for DNACPR
…also in 2007
The Mental Capacity Act 2005
became law
Decisions about CPR must be made on the basis of an
individual assessment of each patient’s case
Advance care planning, including making decisions
about CPR, is an important part of good clinical care for those
at risk of cardiorespiratory arrest
Communication and the provision of information are essential parts of good quality
It is not necessary to initiate discussion about CPR with a patient if there is no reason to believe that the patient is likely
to suffer a cardiorespiratory arrest
Where no explicit decision has been made in advance there
should be an initial
If CPR would not re-start the heart and breathing it should
Where the expected benefit of CPR may be outweighed by the burdens, the patient’s informed
views are of paramount importance
If the patient lacks capacity those close to the patient
should be involved in
discussions to explore the patient’s wishes, feelings,
If a patient with capacity refuses CPR, or a patient
lacking capacity has a valid and applicable advance decision refusing CPR, this should be
A DNAR decision does not override clinical judgement in
the unlikely event of a reversible cause of the
patient’s respiratory or cardiac arrest that does not match the
DNAR decisions apply only to CPR and not to any other
Lots of take-home messages.
Since 2007…
• Joint Statement well-received
• Most comprehensive guidance available
• No major negative feedback
Are you prepared to be shocked?
Audit of Resuscitation Decisions
in a Coronary Care Unit
Resuscitation status recorded in 9/114 (8%)
Discussion possible/appropriate in 104/114 (91%)
Discussion with families occurred in only 3 cases
1 Individual assessment? X
2 Advance care planning X
3 Communication X
4 No need for discussion if risk low N/A
5 Default position OVERUSED
6 No CPR if it won’t work ?
7 Patient’s views paramount X
8 MCA: involve family etc X
9 Patient’s refusal respected N/A 10 Use of clinical judgement N/A 11 DNACPR applies only to CPR N/A
Inadequacies identified: • Hospital organisation
• Initial assessment
• Record-keeping
• Physiological observations not prescribed
• Deterioration not recognised/acted upon
• Care not escalated
• Location of patient
• Consideration of CPR decision
• Resuscitation attempt • Post-arrest care
1 Individual assessment? X
2 Advance care planning X
3 Communication X
4 No need for discussion if risk low N/A
5 Default position OVERUSED
6 No CPR if it won’t work X
7 Patient’s views paramount X
8 MCA: involve family etc X
9 Patient’s refusal respected ?
10 Use of clinical judgement N/A 11 DNACPR applies only to CPR N/A
PRINCIPLE RECOMMENDATIONS
• Explicit CPR decision for all acute admissions
• More consultant involvement
• Escalation for deterioration
• Better understanding of CPR decisions
• Plan for airway management during CPR
Decisions relating to CPR
2013
Do not resuscitate order 'twice added without consent'
A bereaved husband has begun a legal action over "do not resuscitate" orders placed on his wife's medical notes.
6:20PM GMT 05 Nov 2012
Hubby sues on ‘let wife die’ orders
Resuscitate row
13 September 2012
Down's syndrome patient challenges resuscitation order
By Jane Dreaper
Health correspondent, BBC News
A man with Down's syndrome is suing an NHS trust over a hospital's decision to issue a do-not-resuscitate order giving his disability as one of the reasons.
Sunday 4 November 2012 15.27 GMT
Mother of man with cerebral palsy sues hospital over son's DNR order
Elaine Winspear seeks to challenge doctor's 'unilateral' order not to resuscitate son Carl, who died at Sunderland Royal hospital
James Meikle
NHS constitution reform to include new end-of-life care commitments
Measures may include suing health trusts that fail to fully discuss issues and striking off doctors who ignore patients' wishes
Press Association
Guidance will reflect current:
• law• professional codes of practice • ethics
and….I hope…
Decisions relating to CPR
2013
Decisions relating to CPR
2013
Balancing needs of patients and of
clinicians across full spectrum of
Decisions relating to CPR
2013
Guidance is only as effective as
•
the people who use it
12 steps to good CPR decisions
12 steps to good CPR decisions
Communication, communication, communication Communication, communication, communication
12 steps to good CPR decisions
Communication, communication, communication Communication, communication, communication Education, education, education
12 steps to good CPR decisions
Communication, communication, communication Communication, communication, communication Education, education, education
