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 No financial conflicts of interest
A journey CPR decisions How did we get here? Where are we? Where are we going?
How did we get here?
CORONARY CARE UNITS Julian DG Treatment of cardiac arrest in acute myocardial ischaemia and infarction Lancet 1961;ii:840-844 Killip T, Kimball JT Treatment of myocardial infarction in a coronary care unit: a two-year experience with 250 patients Am J Cardiol 1967;20:457-464
Younger, fitter patients admitted to CCU Presumption for CPR
...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 Outcome from CPR poor
CPR not appropriate for all Decisions about CPR.DNR.No code.dnar.dnacpr
The year 2000 The Human Rights Act 1998 became law and
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 Thursday 13 April 2000
March 2001
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 Tendency to discourage CPR decisions
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 care
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 presumption in favour of CPR
If CPR would not re-start the heart and breathing it should not be attempted
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, beliefs and values
If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable advance decision refusing CPR, this should be respected
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 circumstances envisaged
DNAR decisions apply only to CPR and not to any other aspects of treatment
Lots of take-home messages. What did the media take home?
Since 2007 Joint Statement well-received Most comprehensive guidance available No major negative feedback But is it working?
Are you prepared to be shocked? Audit of Resuscitation Decisions in a Coronary Care Unit 2007
Resuscitation status recorded in 9/114 (8%) Discussion possible/appropriate in 104/114 (91%) Discussion with families occurred in only 3 cases (Families not usually visiting during ward rounds)
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
Where are we now?
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 Audit of all CPR attempts
Where are we going?
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 By MATT WILKINSON Published: 06th November 2012
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 The Guardian
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 The Guardian, Sunday 4 November 2012 19.36 GMT
Decisions relating to CPR 2013 Guidance will reflect current: law professional codes of practice ethics and.i hope
Decisions relating to CPR 2013 Balancing needs of patients and of clinicians across full spectrum of settings
Decisions relating to CPR 2013 Guidance is only as effective as the people who use it the way that they use it.
12 steps to good CPR decisions
12 steps to good CPR decisions Communication, communication, communication
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 Education, education, education