Cardiopulmonary resuscitation decisions - integrated adult policy: guidance

The principles of making a DNACPR decision

The circumstances of cardiopulmonary arrest must be anticipated

If the circumstances of a cardiopulmonary arrest cannot be anticipated, it is not possible to make a CPR decision that can have any validity in guiding the clinical team. In order to make an informed decision about the likely outcome of CPR it is essential to be able to think through the likely circumstance(s) in which it might happen for the patient. It is an unnecessary and cruel burden to ask patients or relevant others about CPR when it seems unlikely that circumstances would occur where the patient would require CPR. This should never prevent discussions about resuscitation issues with the patient if they ask to have them.

It should be recognised for some patients with life-limiting illness that the level of frailty and/or co-morbidities may be such that an acute deterioration or a sudden death would not be unexpected. For such patients it may be reasonable to make an advance decision about CPR through sensitive exploration of their goals of care and wishes for emergency treatment even though a cardiorespiratory arrest is not imminently expected.

When CPR would not be successful it should not be offered as a treatment option

Although patients should not be offered CPR when it is clear it will not be successful, open and honest communication is essential to ensure the patient and relevant others have the opportunity to be made aware of the patient's condition, and to be informed of any clinical decision that CPR would not be successful and therefore cannot be offered as a treatment option. Sensitively disclosing the realistic risks of acute deterioration and death allows helpful clarification of the patient's goals of care, end-of-life care wishes and choices around escalation of emergency treatment options. It also gives the patient the opportunity of seeking a second opinion. It is essential to ensure and to document that the patient understands why CPR is not a treatment option for them. Recent case law has clarified that there should be a presumption in favour of consulting the patient, including informing the patient that a clinical DNACPR decision has been made, and the concern of causing simple distress is no longer a justifiable reason to avoid involving the patient. However, it was also recognised that it may be inappropriate to involve the patient if it is very clear that the conversation would cause the patient physical or psychological harm. In this situation it is essential that the rationale for not informing the patient is clearly documented along with a plan to review the patient's ability to accept the information without harm.

"….doctors should be wary of being too ready to exclude patients from the process on the grounds that their involvement is likely to distress them. Many patients may find it distressing to discuss the question whether CPR should be withheld from them in the event of a cardio-respiratory arrest. If however the clinician forms the view that the patient will not suffer harm if she is consulted, the fact that she may find the topic distressing is unlikely to make it inappropriate to involve her. I recognise that these are difficult issues which require clinicians to make sensitive decisions sometimes in very stressful circumstances. I would add that the court should be very slow to find that such decisions, if conscientiously taken, violate a patient's rights under article 8 of the Convention." (Tracey v Cambridge University NHS Trust and the Secretary of State for Health 2014 para 54).

In the situation when death is expected as an inevitable result of an underlying disease, progressive frailty and/or co-morbidities, and the clinical team is as certain as they can be that CPR would not be successful in achieving sustainable life, it should not be attempted. In this situation CPR is not a potential life-prolonging treatment and as such, it may only cause harm by creating a death that is highly medicalised, traumatic, undignified and potentially painful and distressing. In this situation it is not appropriate to offer CPR as it is not a treatment option. However it is essential to share this information as part of discussions with patients and/or their relevant others to explore goals of care and establish anticipatory treatment plans. Where there is disagreement a second opinion may be offered. Although this is recommended as good practice, a second opinion is not a legal requirement where the clinical decision that CPR will not work is endorsed by the multidisciplinary team.

National good practice guidance clarifies that, in most cases, people should be informed, but for some, for example those who know that they are close to the end of their life, such information may be so distressing as to cause the person to suffer physical or psychological harm. ^[4]

Appropriate and sensitive communication and the provision of information are an essential part of good patient care

Good anticipatory care planning should address the circumstances in which CPR might be considered an integral part of escalation/emergency care planning for patients who are deteriorating or are clearly at risk of a sudden deterioration. The timing and nature of conversations about CPR are a matter of judgement for the clinical team. Healthcare professionals should be aware that it is rarely appropriate to discuss DNACPR decisions in isolation from other aspects of escalation/emergency treatment planning in terms of clarifying goals of care and exploring end-of-life care choices. Decisions about CPR are only one of many important aspects of a patient's anticipatory emergency care planning. As such, the need to make an advance decision about CPR can prompt conversations which can help patients achieve a better understanding of their individual situation and provide reassurance that their wishes about realistic treatment options and for their end-of-life care will be respected.

The patient should be given as much information as they wish about their situation. This includes information about CPR in the context of their own illness and sensitive communication around dying and end-of-life issues. Relevant others can be given this information if the patient agrees. It is not the professional's responsibility to decide how much information the patient should receive, their task is to find out how much the patient wishes to know or can understand. The professional must ensure that they do not give selective information; all information that may be relevant to the CPR decision should be provided as requested. As with all discussions and decisions about end-of-life care staff must be aware that some patients will want the support of a trusted religious/spiritual advisor during or after conversations about CPR.

Such discussions can result in upset and even anger for patients and their families and are often uncomfortable for healthcare staff, but anticipation of this should not prevent open and honest communication. Where a DNACPR decision is made on clinical grounds (when CPR will not work) there should be a presumption in favour of informing the patient of this decision, in the context of their goals of care and realistic treatment options. There will be circumstances when clinicians judge that giving information and explanations about CPR decisions would be likely to cause physical or psychological harm to the patient. Faced with such a situation, clinicians should make the decision about CPR that is clinically indicated and record fully their reasons for not explaining it to the patient, including a clear rationale for the judgment of potential physical or psychological harm. They should also ensure that there is ongoing active review of the decision and of the patient's ability to accept explanation of the decision without such harm, so that the patient is informed at the earliest appropriate opportunity. Many patients may find it distressing to discuss a CPR treatment decision; however, if the clinician forms the view that the patient will not suffer physical or psychological harm when consulted, it is appropriate to bring the topic into conversation.

Where CPR will not be successful and the patient lacks capacity to engage in such a conversation those close to the patient (relevant others) must be informed of the decision without delay. It is essential that this conversation happens as part of a wider explanation of the patient's clinical condition which enables exploration and agreement of the goals of care. Achieving a shared understanding of the patient's clinical condition and goals of care should be the aim of the conversation rather than simply to inform of a DNACPR decision. This is a complex conversation and will rarely be appropriate to have by telephone ^[5] . However there may be some well-considered situations where this is clearly the only practicable and appropriate way to achieve such a shared understanding. Clinicians may find themselves in a situation in which they take a conscientious decision that it is not practicable or not appropriate to inform those close to the patient immediately or for the conversation to take place in person. For example, they may believe that contacting and informing them at a particular time will cause them to suffer harm. Where it is not practicable or appropriate to have this conversation with relevant others the reasons must be documented along with a plan to review this.

There are clear benefits for patients and their relevant others in being aware of and understanding the positive purpose of documenting a CPR treatment decision on a specific form and the reassurance that it may prevent an inappropriate, traumatic and distressing emergency response by ambulance crews and police. It is important for patients at home and their carers to be reassured that a call for urgent assistance will be responded to appropriately by whichever service responds.

Discussions about CPR are sensitive and complex and should be undertaken by healthcare staff with the relevant knowledge of the patient's situation and the experience to recognise and respond to the patient's information needs. It is recommended that staff have formal communication skills training in preparation for this clinical responsibility. Any decision-making processes and/or discussions about CPR should be documented in the medical, nursing or multidisciplinary notes.

Quality of life judgements should not be part of the decision-making process for healthcare professionals

This policy supports the view that clinical decisions should be based on immediate health needs, and not on professional opinion on a person's quality of life. This is primarily because opinions on quality of life made by health professionals are very subjective and often at variance with the views of the patient and relevant others. The UN Convention on the Rights of Persons with Disabilities sets out that discrimination on the basis of disability is a breach of the Convention. Article 25 provides that States shall "prevent discriminatory denial of health care ...on the basis of disability."

Where CPR may be medically successful in achieving sustainable life, it is essential to know the patient's fully informed views on the burdens and benefits of this treatment and its likely outcome for them. Where CPR is being offered as a realistic treatment option, healthcare professionals must be clear that they are providing accurate and understandable information about the potential benefits and burdens of this treatment for this patient.

Where no advance decision about CPR has been made, there should be an initial presumption in favour of providing CPR

When no explicit decision has been made about CPR before a cardiopulmonary arrest occurs, and no expressed wishes of the patient are known, it should be presumed that staff would initiate CPR for the patient. However, although this should be the initial presumption, there will be some patients for whom attempting CPR would clearly not be successful, for example a patient in the final stages of a terminal illness where death is imminent and unavoidable. Where CPR will not work it should not be attempted. Any healthcare professional that makes and documents a carefully considered decision not to start CPR in such a situation should be supported by their senior colleagues, employers and professional bodies.