Cardiopulmonary resuscitation (CPR)
When a person has a cardiac or respiratory arrest, CPR can be used in an attempt to restart their heart and breathing and restore their circulation. CPR is invasive, involving chest compressions, delivery of electric shocks from a defibrillator, injection of drugs, and ventilation of the lungs. If delivered promptly, CPR has a good success rate in some circumstances. Generally, however, CPR has a very low success rate and the burdens and risks of CPR include damage to internal organs and rib fractures, and adverse clinical outcomes for the patient such as hypoxic brain damage or increased physical disability. If CPR is not successful in restarting the heart or breathing, and in restoring circulation, it may mean that the patient dies in an undignified and traumatic manner.
When to consider making a Do Not Attempt CPR (DNACPR) decision
If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful in restarting breathing and circulation, discussing, making and recording a decision in advance not to attempt CPR can help to ensure that the patient dies in a dignified and peaceful manner. It may also help the patient achieve their wish of spending their last hours or days at their preferred place of death. These management plans are called Do Not Attempt CPR (DNACPR decisions and are best made in the wider context of advance care planning (see paragraphs 50-55 and glossary). A recorded DNACPR decision is not, in itself, legally binding and should be regarded as a clinical assessment and decision, made and recorded in advance, to guide immediate clinical decision-making in the event of a patient’s cardiorespiratory arrest.
In cases in which CPR might be successful in restarting breathing and circulation, it might still not be seen as clinically appropriate because of the potential for poor clinical outcomes. When considering whether to attempt CPR, you should consider the benefits, burdens and risks of treatment that the patient may need if CPR results in the return of a spontaneous circulation. In cases where you assess that such treatment is unlikely to be clinically appropriate, you may conclude that CPR should not be attempted. Some patients with capacity to make their own decisions may wish to refuse CPR; or in the case of patients who lack capacity it may be judged that attempting CPR would not be of overall benefit to them. However, at the time they suffer a cardiac or respiratory arrest and an immediate decision has to be made, it can be difficult to establish the patient’s wishes and preferences or to get relevant information about their underlying condition to enable a fully informed assessment. So, if a patient has an existing condition that makes cardiac or respiratory arrest likely, establishing a management plan in advance will help to ensure that the patient’s wishes and preferences about treatment can be taken into account and that, if appropriate, a DNACPR decision is made and recorded.
If a patient is admitted to hospital acutely unwell or becomes clinically unstable in their home or other place of care, and they are at foreseeable risk of cardiac or respiratory arrest, a judgement about the likely success of CPR in restarting breathing and circulation and its benefits, burdens and risks should be made as early as possible. You should also check whether any form of advance care planning is already in place and, if the patient lacks capacity, whether they have a legally binding advance refusal.
Discussions about whether to attempt CPR
As with other treatments, decisions made in advance about whether CPR should be attempted must be based on the circumstances of the individual patient and take into account their wishes and preferences. It should also involve discussions with members of the healthcare team as well as (with the patient’s agreement) those close to the patient. You must approach discussions sensitively and bear in mind that some patients or those close to them, may have concerns that decisions not to attempt CPR might be influenced by poorly informed or unfounded assumptions about the impact of disability or advanced age on the patient’s quality of life.
If a patient lacks capacity to make a decision about future CPR, you must consult those close to the patient as part of the decision making process. You must approach discussions sensitively and bear in mind that some people may have concerns that some decisions not to attempt CPR might be influenced by poorly informed or unfounded assumptions about the impact of disability or advanced age on the patient’s quality of life. In addition, the views of members of the healthcare team involved in their care may be valuable in assessing the likelihood that CPR would be successful in restoring the patient’s breathing and circulation or whether successful CPR would likely be of overall benefit to them. You must make reasonable efforts to discuss a patient’s CPR status with these healthcare professionals.
When CPR will not be successful in restarting breathing and circulation
If a patient is at foreseeable risk of cardiac or respiratory arrest and you judge that CPR should not be attempted, because it will not be successful in restarting the patient’s heart and breathing and restoring circulation, you must sensitively discuss this with the patient unless this would cause them serious harm. In this context, ‘serious harm’ means more than that the patient might become upset. The purpose of the dialogue is to reach a shared understanding with the patient about their situation, your judgement and your reasons for reaching it. You must listen to the patient and you should encourage them to ask questions. As part of these discussions, you should explore with the patient the type of information they want or need, their wishes or fears and explain that they have a right to seek a second opinion. While some patients may want to have these discussions, others may not. You should not force a discussion or information onto the patient if they do not want it. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.
If the patient does not wish to know about or discuss a DNACPR decision, you should seek their agreement to share with those close to them, with carers and with others, the necessary information they may need to know in order to support the patient’s treatment and care. You should emphasise to the patient that they may discuss the topic at any time if they decide that they want to.
If a patient lacks capacity, you must consult with any legal proxy and others close to the patient about the DNACPR decision and the reasons for it unless it is not practicable or appropriate to do so. These discussions should take place at the earliest practicable opportunity and should include a sensitive and careful explanation that the intention is to spare the patient treatment that will be of no benefit, not to withhold any other care or treatment the patient will need.
When CPR may be successful in restarting breathing and circulation
Patients who have capacity
If CPR may be successful in restarting a patient’s heart and breathing and restoring circulation, the benefits must be weighed against the potential burdens and risks. This is not solely a clinical decision. You must offer the patient opportunities to discuss (with support if they need it) whether CPR should be attempted in the event of a future cardiac or respiratory arrest. You must approach this sensitively and should not force a discussion or information onto the patient if they do not want it. However, if they are prepared to talk about it, you must provide them with accurate information about the burdens and risks of CPR, including the likely clinical and other outcomes if CPR does restore breathing and circulation. This should include a sensitive explanation of the extent to which other intensive treatments and procedures may not be seen as clinically appropriate after the return of spontaneous circulation. For example, in some cases, prolonged support for multi-organ failure in an intensive care unit may not be clinically appropriate or of overall benefit even though the patient’s heart has been restarted.
If a patient wishes to receive CPR and it is your considered judgement that CPR would not be clinically appropriate for the patient, you must sensitively explore their reasons for requesting it, their understanding of what it would involve, and their expectations about the likely outcome. As part of this, you should make sure that they have accurate information about the nature of and, for example, the length of survival and level of recovery that they might realistically expect if they were successfully resuscitated. You should also try to reach agreement; for example, limited CPR interventions could be agreed in some cases. When the benefits, burdens and risks are finely balanced, the patient’s request will usually be the deciding factor. If, after discussion, you still consider that CPR would not be clinically appropriate, there is no obligation to provide it in the circumstances envisaged. You must explain your reasons and any other options that may be available to the patient, including their right to seek a second opinion.
Patients who lack capacity
If a patient lacks capacity to make a decision about future CPR, you must consult any legal proxy who has authority to make the decision for the patient unless it is not practicable or appropriate to do so. If there is no legal proxy with relevant authority, you must discuss the issue with those close to the patient and with the healthcare team. You must make all reasonable efforts to have these consultations or discussions at the earliest practicable opportunity and they should be approached with sensitivity. In your consultations or discussions, you must follow the decision-making model in paragraph 16. In particular, you should be clear about the role that others are being asked to take in the decision-making process. If they do not have legal authority to make the decision, you should be clear that their role is to advise you and the healthcare team about the patient’s wishes and preferences to inform the decision about whether attempting CPR would be of overall benefit to the patient. You must not give them the impression that it is their responsibility to decide whether CPR will be of overall benefit to the patient, or that they are being asked to decide whether or not CPR will be attempted. You should provide any legal proxy and those close to the patient, with the same information about the nature of CPR and the burdens and risks for the patient as explained in paragraphs 137.
If the legal proxy requests that CPR is attempted in future, in spite of the burdens and risks, or they are sure that this is what the patient would want, and it is your considered judgement that CPR would not be clinically appropriate for the patient, you must sensitively explore the reasons for the proxy’s request, their understanding of what it would involve, and their expectations about the likely outcome. If after further discussion you still consider that attempting CPR would not be clinically appropriate for the patient, there is no obligation to provide it in the circumstances envisaged. You should explain your reasons and any other options that may be available to the legal proxy, including their right to seek a second opinion.
If there is disagreement about whether CPR should be provided, you should try to resolve it by following the guidance in paragraphs 47 - 49.
You should aim to reach a consensus about what treatment and care would be of overall benefit to a patient who lacks capacity. Disagreements may arise between you and those close to the patient, or between you and members of the healthcare team, or between the healthcare team and those close to the patient. Depending on the seriousness of any disagreement, it is usually possible to resolve it; for example, by involving an independent advocate, seeking advice from a more experienced colleague, obtaining a second opinion, holding a case conference, or using local mediation services. In working towards a consensus, you should take into account the different decision-making roles and authority of those you consult, and the legal framework for resolving disagreements.
If, having taken these steps, there is still disagreement about a significant decision, you must follow any formal steps to resolve the disagreement that are required by law or set out in the relevant code of practice. You should make sure you are aware of the different people you must consult, their different decision-making roles and the weight you must attach to their views. You should consider seeking legal advice and may need to apply to an appropriate court or statutory body for review or for an independent ruling. Your patient, those close to them and anyone appointed to act for them should be informed as early as possible of any decision to start legal proceedings, so they have the opportunity to participate or be represented.
In situations in which a patient with capacity to decide requests a treatment and does not accept your view that the treatment would not be clinically appropriate, the steps suggested above for resolving disagreement may also be helpful.
Recording and communicating CPR decisions
Any discussions with a patient, or with those close to them, about whether to attempt CPR, and any decisions made, should be documented in the patient’s record and any advance care plan.37 If a DNACPR decision is made and there has been no discussion with the patient because they indicated a wish to avoid it, or because you considered that discussion with the patient would cause them serious harm, you should document this fully in the patient’s records.
Treatment and care after a DNACPR decision
In your consultations and discussions about CPR, you must make it clear to the healthcare team, the patient and those close to the patient that a DNACPR decision applies only to CPR. It does not imply that other treatments will be withdrawn or withheld. Other treatment and care will be provided if it is clinically appropriate and agreed to by a patient with capacity, or if it is of overall benefit to a patient who lacks capacity.
A DNACPR decision should not override your clinical judgement about CPR if the patient experiences cardiac or respiratory arrest from a potentially reversible cause, that was neither discussed nor envisaged when the DNACPR decision was recorded. If a patient with a DNACPR decision in place has a planned procedure which could precipitate a cardiorespiratory arrest, such as an operation under general anaesthesia, there should be careful discussion with the patient (or with those close to a patient who lacks capacity) beforehand to reach agreement about possible temporary suspension of the DNACPR decision.
Emergencies and CPR
Emergencies can arise when there is no time to access all relevant information about the patient’s condition and the likely outcome of CPR; when no previous DNACPR decision is in place; and when it is not possible to find out the patient’s views. In these circumstances, CPR should be attempted, unless, in your clinical judgement, it will not be successful in restarting the patient’s breathing and circulation.