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Decisions Relating to Cardiopulmonary Resuscitation

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Overview

Decisions regarding cardiopulmonary resuscitation (CPR) are made by the patient’s medical team. CPR within the hospital is only around 15-20% successful and may be much lower if there are other comorbidities present. Successful CPR outside of hospital is around 5-10%.

Attempting CPR can have adverse effects such as rib fractures, and hepatic or splenic ruptures, and in many cases, patients need to stay in intensive care units for long periods, often needing artificial ventilation, renal replacement therapy, and circulatory support. There is also the risk of brain damage and subsequent permanent disability. It is therefore essential to determine whether the benefits of CPR outweigh the risks.

It is important to note that a ‘Do not attempt cardiopulmonary resuscitation (DNACPR)’ document is not set in stone. Patients sometimes improve and their prognosis changes. In these situations, DNACPR orders are reconsidered.

In summary:

  • DNACPRs only apply to CPR
    • All other treatments should continue
  • Patients can refuse CPR but cannot demand that it be performed
  • DNACPRs may be put in place if:
    • CPR is unlikely to be successful
    • The patient refuses CPR
    • It may be successful but would leave a quality of life that is not in the patient’s best interests.
  • All DNACPR discussions must be documented
  • If the form is signed by a junior doctor, it must be signed by a consultant as soon as possible.
  • If the patient has capacity, they must be informed about decisions relating to CPR unless they refuse.
  • If the patient does not have capacity, those close to the patient should be informed about decisions relating to CPR.

Decision-Making

Some questions need to be addressed when making decisions relating to cardiopulmonary resuscitation:

  • Is cardiorespiratory arrest a clear possibility for the patient?
    • If no, then it is not necessary to discuss CPR with the patient unless they say they would like to
  • Is there a realistic chance that CPR could be successful?
    • If no, then a DNACPR may be put in place.
    • It is essential to inform the patient and explain the decision, as well as informing those close to the patient unless the patient wishes to keep this confidential.
    • If the patient lacks capacity and has a Lasting Power of Attorney (LPA) for Health and Welfare, the LPA should be informed about the DNACPR and the reasons for it.
    • If the patient lacks capacity, the DNACPR decision should be explained to those close to the patient immediately. If this is not possible, the reasons why must be documented.
    • If the DNACPR decision is not accepted by the patient, then their LPA, or someone close to them, a second opinion should be offered.
  • Does the patient lack capacity and have an advance decision refusing CPR or have an appointed LPA?
    • If yes and the patient has made an advance decision refusing CPR and it is valid, then this must be respected.
    • If an LPA has been appointed, they must be consulted.
  • Does the patient lack capacity?
    • If yes then discussions with those close to the patient must take place to guide a decision in the patient’s best interests.
    • If the patient is a child/young person, those with parental responsibility should be involved in the decision where appropriate unless the patient objects.
  • Is the patient willing to discuss their wishes regarding CPR?
    • If yes, the patient must be involved in deciding whether or not CPR will be attempted in the event of a cardiac arrest.
    • If no, respect and document their refusal. Discussion with those close to the patient may help guide a decision in the patient’s best interests unless confidentiality restrictions prevent this.

ReSPECT

Overview

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process creates a summary of personalised plans for a person’s care in a future emergency in which they do not have the capacity to make or express choices. This can include but is not limited to, death and cardiac arrest. This allows for agreed realistic clinical plans to be put in place that respects the patient’s preferences and clinical judgement.

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