Cardiopulmonary resuscitation

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Cardiopulmonary resuscitation (CPR) refers to procedures employed to try to sustain basic circulation in a patient in cardiac arrest or respiratory arrest. The main procedures are mechanical compression of the thorax to produce blood flow and artificial ventilation. The closed chest procedure was first described in 1960[1] for use in the peri-operative cardiac arrest situation, but it should be realised that the possibility of offering open chest CPR to general hospital inpatients had been raised the same year[2]. Formal policies on its use were first developed in the mid 1970's[3][4], in response to the evolving ethical issues the technique created around the process of dying.

LogoKeyPointsBox.pngBlame the media: CPR usually fails, particularly in ill, rather than eg drowned, people, however first responders may feel guilty, and the ignorant and gullible criticise others, when a miracle fails to happen

In specific circumstances, CPR can be life-saving, but, in the worst kind of in-hospital cardiac arrest - asystole - the success rate of CPR is dismal.

Dramatic coverage in TV serials and films may have raised unrealistic expectations and leave those whose relatives have died, or who have attempted unsuccessfully to resuscitate someone disappointed. Out of hospital CPR can be successful, especially if bystander witnessed and if delay to defibrillator is minimal where rates of over 80% success might occur[5]. In these circumstances there is no present evidence for superiority of rescue breathing combined with chest compression as outcomes with chest compression alone until arrival of trained staff are similar.[6] Deaths from collapses at organised sporting events may have decreased due to a combination of public training and appropriate equipment availability[7].

Contents

Do not attempt cardiopulmonary resuscitation decisions

These need to be undertaken in the context of differing international legal frameworks that are still actively evolving. Some cultures have evolved in 40 years from not expecting explicate decisions to expecting next of kin to be consulted by telephone at the time of an emergency presentation if the CPR is not to be offered[8].

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Please refer to the full guideline above but a brief synopsis as of the 2016 clarification is:

  1. Consider explicitly, and whenever possible making specific anticipatory decisions about, whether or not to attempt CPR is part of good-quality care for those approaching the end of life and/or are at risk of cardiorespiratory arrest
  2. If cardiorespiratory arrest is not predicted or reasonably foreseeable in the current circumstances or treatment episode, it is not necessary to initiate discussion about CPR with a patient.
  3. For many, anticipatory decisions about CPR are best made in the wider context of advance care planning, before a crisis necessitates a hurried decision in an emergency setting.
  4. Decisions about CPR must be made on the basis of a careful assessment of an individual’s situation. These decisions should never be dictated by a ‘blanket’ policy.
  5. Decisions about CPR should be subject to review based on the person’s individual circumstances. In the setting of an acute illness, review should be sufficiently frequent to allow a change of decision (in either direction) in response to the person’s clinical condition. In end-of-life care for a progressive, irreversible condition there may be little or no need for review.
  6. Triggers for review should include requests from the patient or those close to them, substantial change in the patient’s clinical condition or prognosis and transfer of the patient (including transfer within a healthcare establishment).
  7. For a person in whom CPR may be successful, when a decision about future CPR is being considered there must be a presumption in favour of involvement of the person in the decision-making process. If they lack capacity those close to them must be involved in discussions to explore the person’s wishes, feelings, beliefs and values in order to reach a best interests decision. It is important to ensure that those asked understand that (in the absence of an applicable power of attorney or court-appointed deputy or guardian) they are not the final decision-makers, but they have an important role in helping the healthcare team to make a decision that is in the patient’s best interests.
  8. If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable advance decision to refuse treatment, specifically refusing CPR, this must be respected.
  9. If a person is dying as an inevitable result of underlying disease or a catastrophic health event, and CPR would not re-start the heart and breathing for a sustained period, CPR should not be attempted.
  10. Even when CPR has no prospect of success, there must be a presumption in favour of explaining the need and basis for a DNACPR decision to a patient, or to those close to a patient who lacks capacity. It is not necessary to obtain the consent of a patient or of those close to a patient to a decision not to attempt CPR that has no realistic prospect of success. The patient and those close to the patient do not have a right to demand treatment that is clinically inappropriate and healthcare professionals have no obligation to offer or deliver such treatment.
  11. Where there is a clinical need for a DNACPR decision in a dying patient for whom CPR offers no realistic prospect of success, that decision should be made and explained to the patient and those close to the patient at the earliest practicable and appropriate opportunity.
  12. Where a patient or those close to a patient disagree with a DNACPR decision, a second opinion should be offered. Endorsement of a DNACPR decision by all members of a multidisciplinary team may avoid the need to offer a further opinion.
  13. Effective communication is essential to ensure that decisions about CPR are made well and understood by all those involved. There should be clear, accurate, honest and timely communication with the patient and (unless the patient has requested confidentiality) those close to the patient, including provision of information and checking their understanding of what has been explained to them. Agreeing broader goals of care with patients, and those close to patients is an essential prerequisite to enabling each of them to understand decisions about CPR in context.
  14. Unnecessary delay in offering discussions, explanations and information about CPR decisions can lead to misunderstanding and dissatisfaction. Delivering these communications in an inappropriate or insensitive way can also lead to dissatisfaction. A decision to delay or avoid communication of a decision to a patient must be based on that communication being likely to cause the patient physical or psychological harm. A decision to delay communication of a decision to those close to a patient without capacity must be based on that communication being either not practicable or not appropriate in the circumstances.
  15. Any decision about CPR should be communicated clearly to all those involved in the patient’s care.
  16. It is essential that healthcare professionals, patients and those close to patients understand that a decision not to attempt CPR applies only to CPR and not to any other element of care or treatment. A DNACPR decision must not be allowed to compromise high quality delivery of any other aspect of care.
  17. A DNACPR decision does not override clinical judgement in the unlikely event of a reversible cause of respiratory or cardiac arrest that does not match the circumstances envisaged when that decision was made and recorded. Examples of such reversible causes include but are not restricted to – choking, a displaced tracheal tube or a blocked tracheostomy tube.
  18. Decisions about CPR must be free from any discrimination, for example in respect of a disability. A best-interests decision about CPR is unique to each person and is to be guided by the quality of future life that the person themselves would regard as acceptable or, in the case of children taken into account the views of the child and parents.
  19. Clear and full documentation of decisions about CPR, the reasons for them, and the discussions that informed those decisions, is an essential part of high-quality care. This often requires documentation in the health record of detail beyond the content of a specific CPR decision form. Where such discussions are not practicable or not appropriate, the reasons for this must be documented fully.
  20. A CPR decision form in itself is not legally binding. The form should be regarded as an advance clinical assessment and decision, recorded to guide immediate clinical decision-making in the event of a patient’s cardiorespiratory arrest or death. The final decision regarding whether or not attempting CPR is clinically appropriate and lawful rests with the healthcare professionals responsible for the patient’s immediate care at that time.
  21. Use where possible subject to local agreement, a CPR decision form that may be paper-based or electronic, and that is used, recognised and accepted across geographical and organisational boundaries
  22. Recorded decisions about CPR should accompany a patient when they move from one setting to another.
  23. Records of decisions about CPR must be accurate and up-to-date. Systems (whether paper-based or electronic) for recording these decisions must be reliable and responsive, in particular, to any change in the decision about CPR.
  24. Where no explicit decision about CPR has been considered and recorded in advance there should be an initial presumption in favour of CPR. However, in some circumstances where there is no recorded explicit decision (for example for a person in the advanced stages of a terminal illness where death is imminent and unavoidable and CPR would not be successful) a carefully considered decision not to start inappropriate CPR should be supported
  25. Failure to make timely and appropriate decisions about CPR will leave people at risk of receiving inappropriate or unwanted attempts at CPR as they die. The resulting indignity, with no prospect of benefit, is unacceptable, especially when many would not have wanted CPR had their needs and wishes been explored.

There is no ethical or legal obligation on doctors - or other healthcare workers, including nurses and paramedics - to provide a treatment that is not thought likely to benefit a patient, even if the patient demands it. However it transpires that because of the human rights act and the importance of the decision in the case of CPR there is a potential duty to discuss such a decision with a competent patient.

Some organisations will insist that unless there is a "Do not attempt cardiopulmonary resuscitation" (DNAR) notice in a patient's notes, all non-medical staff, and any doctors who do not know the patient's condition, are obliged to institute CPR, even for patients in whom this is clearly futile. This is against current guidance which delegates the decision to the senior registered doctor or nurse attending the patient at the time. There have been cases of patients who are receiving terminal care, and for whom CPR is instituted when their heart stops - which means they suffer what many consider a violent, undignified and distressing death, instead of a peaceful one. Indeed, it is perhaps a little surprising that no healthcare worker has ever (to this editor's knowledge) been sued for assault after providing DNAR when it was futile and inappropriate. (It is only slightly surprising; in general the courts are far more lenient towards those who do something with good intentions, however inappropriate, than they are to those who are alleged to have not done something that somebody considers might have been appropriate.)

Some organisations also require that a particular DNAR form must be used, on particular paper, not photocopied... Unless they have a contract explicitly requiring it, there is no obligation on a doctor not employed by that organisation to comply with these requirements. If its staff proceed to undertake CPR despite the dcoumented (albeit not on their "correct" forms) evidence that this is contrary to the patient's wishes patient - i.e. when there is good reason to think they do not have consent, or implied consent - this is assault. If it goes to court, their staff could attempt to explain to the court that they were legitimately in doubt about the validity of the refusal of consent to CPR because the form didn't have, say, the red borders required by their Trust; but this is unlikely to carry much (if any) weight.

Issuing a DNAR notice may, in itself, be distressing, however. Following a 2014 court case it may seem necessary to discuss a DNAR decision with patients and/or their relatives (although the full judgement is more nuanced than it may have appeared from the press coverage).[9][10][11]. This case resulted in updated guidelines in the UK[12]. If it is considered that discussing a DNAR decision with the patient and/or their relatives would cause undue distress, then a DNAR decision may be made without doing so; but the decision-making process and the factors considered must be carefully documented in the patient's notes to avoid the possibility of a successful legal claim by distressed relatives.

If a patient has capacity there is no legal obligation to discuss anything with relatives (unless in England and Wales they are the nominated attorney/deputy for health and welfare matters); but discussing a DNAR decision with them in advance may mean that they are less distressed at the time of death, and less likely to have unrealistic expectations. However a 2015 High Court[13] has defined that where the patient lacks capacity it is necessary where practicable and appropriate to consult anyone engaged in caring for the person or interested in his welfare

Capacity

An assessment of capacity for a simple but very important decision that should be communicated appropriately may needs to be undertaken in the context of some legal frameworks. In others no communication of such a decision is assumed. This can cause health care workers moving from one jurisdiction to another or where case law has evolved during a practice lifetime considerable problems.

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All countries have agreed to implement the Convention on the International Protection of Adults signed at the Hague on 13th January 2000 but this is taking sometime in practice. There are inconvenient burdens in terms of best interest decision making and its documentation to negotiate often as this is implemented

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See Mental Capacity Act 2005. The necessity where practicable and appropriate to consult anyone engaged in caring for the person or interested in his welfare has been interpreted by the courts in a way that many health professionals expect to lead to a decrease in anticipatory care DNR decisions

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See Incapacity (Scotland) Act 2000

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As of June 2015 the Mental Capacity Bill had reached its second stage

Pregnancy

Pregnancy is a rare special case.

The key differences:

  1. Wedge the maternal pelvis to ensure adequate return of blood via the inferior vena cava
  2. In late pregnancy urgent (ideally within 5 minutes in A&E) delivery of the child (regardless of viability) must be undertaken. Successful saving of both mother and child is possible[14].

See Also

External Links

References

  1. KOUWENHOVEN WB, JUDE JR, KNICKERBOCKER GG. Closed-chest cardiac massage. JAMA. 1960 Jul 9; 173:1064-7.
  2. SNYDER WH. Cardiac arrest--successful resuscitation in the hospital outside the operating rooms. California medicine. 1960 Feb; 92:159-62.
  3. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). V. Medicolegal considerations and recommendations. JAMA. 1974 Feb 18; 227(7):Suppl:864-8.
  4. Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. The New England journal of medicine. 1976 Aug 12; 295(7):364-6.(Link to article – subscription may be required.)
  5. van de Sandt F, Umans V. Acute cardiac events and deployment of emergency medical teams and automated external defibrillators in large football stadiums in the Netherlands. European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology. 2009 Oct; 16(5):571-5.(Link to article – subscription may be required.)
  6. Rea TD, Fahrenbruch C, Culley L, Donohoe RT, Hambly C, Innes J, Bloomingdale M, Subido C, Romines S, Eisenberg MS. CPR with chest compression alone or with rescue breathing. The New England journal of medicine. 2010 Jul 29; 363(5):423-33.(Link to article – subscription may be required.)
  7. Drezner JA. Preparing for sudden cardiac arrest--the essential role of automated external defibrillators in athletic medicine: a critical review. British journal of sports medicine. 2009 Sep; 43(9):702-7.(Link to article – subscription may be required.)
  8. a b Decisions relating to Cardiopulmonary Resuscitation (3rd edition - 1st revision. Resuscitation Council(UK), BMA, RCG, RCN June 2016
  9. 2014 EWCA Civ 822. Case No: C1/2013/0045
  10. Merry Varney. Landmark judgement in resuscitation case. Leigh Day Blog. 2014 (Last updated 17 June). Last viewed 2014 (6 July).
  11. Dyer C. Doctors should consult patients before imposing non-resuscitation notices unless it would cause harm, Court of Appeal rules. BMJ (Clinical research ed.). 2014; 348:g4094.(Epub)
  12. Decisions relating to Cardiopulmonary Resuscitation BMA, RCG, RCN October 2014
  13. Winspear v City Hospitals Sunderland NHS Foundation Trust [2015 EWHC 3250]
  14. Engels PT, Caddy SC, Jiwa G, Douglas Matheson J. Cardiac arrest in pregnancy and perimortem cesarean delivery: case report and discussion. CJEM. 2011 Nov; 13(6):399-403.