General Medical Council
Working with doctors Working for patients
29 Mar 2017
Clarification on the GMC's guidance
We absolutely agree that compassionate and respectful care is vital for people who are dying. Our guidance, Treatment and care towards the end of life, provides advice for all doctors on how to achieve this across all aspects of care, recognising that this is an area of practice that is emotionally demanding and ethically complex.
We also have a variety of resources available to help doctors apply our guidance in practice and to help them to have conversations about advance care planning, including resuscitation decisions.
We agree (and paragraph 128 of our guidance states) that CPR has a very low success rate, that it has harmful side effects, can lead to adverse clinical outcomes, and may lead to the patient dying in an undignified and traumatic manner. We do not advise that, irrespective of the patient’s underlying condition, doctors must attempt CPR when there is no Do Not Attempt CPR Order (DNACPR) in place. Nor do we require CPR to be attempted for patients whose heart/breathing stops as part of the expected (natural) dying process.
In emergency situations where no DNACPR is in place and it isn’t possible to find out the patient’s views, then CPR should be attempted, unless the doctor judges that CPR will not work for that patient (paragraph 146).
In non-emergency situations, good ethical practice is to explore what the patient would want. In situations where the patient does not have capacity to make this decision, doctors should explore this with those close to the patient (paragraphs 140-141).
Sometimes families worry that this means the person won’t get other aspects of high quality palliative care or will be denied treatments. This may be coupled with a misunderstanding of the likely success rate from CPR and a lack of awareness about the risks and impact. So having the discussion as part of broader consideration of what a person would want towards the end of their life can help allay fears and enable people to make more empowered decisions.
Recent case law – the Tracey and Winspear judgments – makes it clear that patients and/or families must be consulted about putting a DNA CPR in place.
Paragraph 129 of our guidance sets out that, where cardiac or respiratory arrest is an expected part of the ‘natural’ dying process for an individual, then having a DNACPR in place helps to avoid inappropriate CPR attempts.
Our guidance was informed by a working group who responded to a number of key points raised during a public consultation. We were made aware that, in some practice settings, there were organisational policies setting a ‘default’ requirement to attempt CPR in emergencies where no DNACPR was in place. We wanted to provide some reassurance to doctors that if, in such circumstances, they made a clinical judgement that attempting CPR was not appropriate, we would find that acceptable.
We were asked to make clear that cardiac or respiratory arrest could be part of the natural dying process. In such cases, attempting CPR would not be appropriate. And doctors should consider making a DNACPR decision as part of advance care planning for such patients. Those supporting this approach felt that having GMC guidance to this effect would help increase the number of appropriate DNACPR orders being made, in more healthcare settings including patients’ homes.
Joint guidance from the BMA, RCN and Resuscitation Council (UK)
Since our guidance was published, our position has been reinforced by advice in the June 2016 joint BMA, RCN and Resuscitation Council (UK) guidelines. We participated in the development of these joint guidelines which outline that there should be an initial presumption in favour of CPR when there is no recorded CPR decision.
This guidance also emphasises that:
‘There will be some people for whom attempting CPR is clearly inappropriate; for example, a person in the advanced stages of a terminal illness where death is imminent and unavoidable and CPR would not be successful, but for whom no formal CPR decision has been made and recorded.
‘Also, there will be cases where healthcare professionals discover patients with features of irreversible death – for example, rigor mortis. In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies.’
We have also been involved in the development of the new ReSPECT form and hope that its wider adoption will assist doctors and patients to have these conversations, and support the delivery of person-centred, compassionate end of life care.
We appreciate these matters are often difficult. As with all our guidance, we expect doctors to use their professional judgment to apply it to the situations they face, to work in partnership with patients, and to be prepared to justify their decisions.
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