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Treatment and care towards the end of life: good practice in decision making

Cardiopulmonary resuscitation (CPR)

128

When someone suffers sudden cardiac or respiratory arrest, CPR attempts to restart their heart or breathing and restore their circulation. CPR interventions are invasive and include chest compressions, electric shock by an external or implanted defibrillator, injection of drugs and ventilation. If attempted promptly, CPR has a reasonable success rate in some circumstances. Generally, however, CPR has a very low success rate and the burdens and risks of CPR include harmful side effects such as rib fracture and damage to internal organs; adverse clinical outcomes such as hypoxic brain damage; and other consequences for the patient such as increased physical disability. If the use of 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

129

If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful, making and recording an advance decision not to attempt CPR will help to ensure that the patient dies in a dignified and peaceful manner. It may also help to ensure that the patient’s last hours or days are spent in their preferred place of care by, for example, avoiding emergency admission from a community setting to hospital. These management plans are called Do Not Attempt CPR (DNACPR) orders, or Do Not Attempt Resuscitation or Allow Natural Death decisions.

130

In cases in which CPR might be successful, it might still not be seen as clinically appropriate because of the likely 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 is successful. 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, it can be difficult to establish the patient’s wishes or to get relevant information about their underlying condition to make a considered judgement at the time they suffer a cardiac or respiratory arrest and an urgent decision has to be made. 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.

131

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 benefits, burdens and risks of CPR should be made as early as possible.

Discussions about whether to attempt CPR

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As with other treatments, decisions about whether CPR should be attempted must be based on the circumstances and wishes of the individual patient. This may involve discussions with the patient or with those close to them, or both, as well as members of the healthcare team. 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.

133

If a patient lacks capacity to make a decision about future CPR, the views of members of the healthcare team involved in their care may be valuable in assessing the likely clinical effectiveness of attempting CPR and whether successful CPR is likely to be of overall benefit. You should make every effort to discuss a patient’s CPR status with these healthcare professionals.

When CPR will not be successful

134

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 carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made. You should not make assumptions about a patient’s wishes, but should explore in a sensitive way how willing they might be to know about a DNACPR decision. While some patients may want to be told, others may find discussion about interventions that would not be clinically appropriate burdensome and of little or no value. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.

135

If you conclude that 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 information they may need to know in order to support the patient’s treatment and care.

136

If a patient lacks capacity, you should inform any legal proxy and others close to the patient about the DNACPR decision and the reasons for it.

When CPR may be successful

Patients who have capacity

137

If CPR may be successful in restarting a patient’s heart and breathing and restoring circulation, the benefits of prolonging life must be weighed against the potential burdens and risks. But this is not solely a clinical decision. You should offer the patient opportunities to discuss (with support if they need it) whether CPR should be attempted in the circumstances that may surround 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 interventions, including the likely clinical and other outcomes if CPR is successful. This should include sensitive explanation of the extent to which other intensive treatments and procedures may not be seen as clinically appropriate after successful CPR. For example, in some cases, prolonged support for multi-organ failure in an intensive care unit may not be clinically appropriate even though the patient’s heart has been restarted.

138

You should explain, in a sensitive manner, any doubts that you and the healthcare team may have about whether the burdens and risks of CPR would outweigh the benefits, including whether the level of recovery expected after successful CPR would be acceptable to the patient.

139

Some patients may wish to receive CPR when there is only a small chance of success, in spite of the risk of distressing clinical and other outcomes. If it is your considered judgement that CPR would not be clinically appropriate for the patient, you should make sure that they have accurate information about the nature of possible CPR interventions and, for example, the length of survival and level of recovery that they might realistically expect if they were successfully resuscitated. You should explore the reasons for their request and 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, you are not obliged to agree to attempt it in the circumstances envisaged. You should explain your reasons and any other options that may be available to the patient, including seeking a second opinion.

Patients who lack capacity

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If a patient lacks capacity to make a decision about future CPR, you should consult any legal proxy who has authority to make the decision for the patient. 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. 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. You must not give them the impression that it is their responsibility to decide whether CPR will be of overall benefit to the patient. 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 - 138.

16

Taking account of the considerations in paragraph 15, this is the decision-making model that applies if a patient lacks capacity:

  1. The doctor, with the patient (if they are able to contribute) and the patient’s carer12, makes an assessment of the patient’s condition taking into account the patient’s medical history and the patient and carer’s knowledge and experience of the condition.
  2. The doctor uses specialist knowledge, experience and clinical judgement, together with any evidence about the patient’s views (including advance statements, decisions or directives), to identify which investigations or treatments are clinically appropriate and are likely to result in overall benefit for the patient.
  3. If the patient has made an advance decision or directive refusing a particular treatment, the doctor must make a judgement about its validity and its applicability to the current circumstances. If the doctor concludes that the decision or directive is legally binding, it must be followed in relation to that treatment. Otherwise it should be taken into account as information about the patient’s previous wishes. (See paragraphs 67 - 74 on assessing the legal status of advance decisions and directives.)
  4. If an attorney or other legal proxy has been appointed to make healthcare decisions for the patient, the doctor explains the options to the legal proxy (as they would do for a patient with capacity), setting out the benefits, burdens and risks of each option. The doctor may recommend a particular option which they believe would provide overall benefit for the patient. The legal proxy weighs up these considerations and any non-clinical issues that are relevant to the patient’s treatment and care, and, considering which option would be least restrictive of the patient’s future choices, makes the decision about which option will be of overall benefit. The doctor should offer support to the legal proxy in making the decision, but must not pressurise them to accept a particular recommendation.
  5. As well as advising the legal proxy, the doctor must involve members of the healthcare team and those close to the patient13 as far as it is practical and appropriate to do so14, as they may be able to contribute information about the patient that helps the proxy to reach a decision. If the legal proxy does not have the power to make a particular decision, the doctor must take account of the proxy’s views (as someone close to the patient) in the process of reaching a decision.
  6. In circumstances in which there is no legal proxy with authority to make a particular decision for the patient, and the doctor is responsible for making the decision, the doctor must consult with members of the healthcare team and those close to the patient (as far as it is practical and appropriate to do so) before reaching a decision. When consulting, the doctor will explain the issues; seek information about the patient’s circumstances; and seek views about the patient’s wishes, preferences, feelings, beliefs and values. The doctor may also explore which options those consulted might see as providing overall benefit for the patient, but must not give them the impression they are being asked to make the decision. The doctor must take the views of those consulted into account in considering which option would be least restrictive of the patient’s future choices and in making the final decision about which option is of overall benefit to the patient.
  7. In England and Wales, if there is no legal proxy, close relative or other person who is willing or able15 to support or represent the patient and the decision involves serious medical treatment16, the doctor must approach their employing or contracting organisation about appointing an Independent Mental Capacity Advocate (IMCA), as required by the Mental Capacity Act 2005 (MCA). The IMCA will have authority to make enquiries about the patient and contribute to the decision by representing the patient’s interests, but cannot make a decision on behalf of the patient.
  8. If a disagreement arises about what would be of overall benefit, the doctor must attempt to resolve the issues following the approach set out in paragraphs 47 - 48.
  9. If a legal proxy or other person involved in the decision making asks for a treatment to be provided which the doctor considers would not be clinically appropriate and of overall benefit to the patient, the doctor should explain the basis for this view and explore the reasons for the request. If after discussion the doctor still considers that the treatment would not be clinically appropriate and of overall benefit, they are not obliged to provide it. However, as well as explaining the reasons for their decision, the doctor should explain to the person asking for the treatment the options available to them. These include the option of seeking a second opinion, applying to the appropriate statutory body for a review (Scotland), and applying to the appropriate court for an independent ruling. For further guidance on acting on advance requests for treatment see paragraphs 63 - 66.
137

If CPR may be successful in restarting a patient’s heart and breathing and restoring circulation, the benefits of prolonging life must be weighed against the potential burdens and risks. But this is not solely a clinical decision. You should offer the patient opportunities to discuss (with support if they need it) whether CPR should be attempted in the circumstances that may surround 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 interventions, including the likely clinical and other outcomes if CPR is successful. This should include sensitive explanation of the extent to which other intensive treatments and procedures may not be seen as clinically appropriate after successful CPR. For example, in some cases, prolonged support for multi-organ failure in an intensive care unit may not be clinically appropriate even though the patient’s heart has been restarted.

138

You should explain, in a sensitive manner, any doubts that you and the healthcare team may have about whether the burdens and risks of CPR would outweigh the benefits, including whether the level of recovery expected after successful CPR would be acceptable to the patient.

141

If the legal proxy requests that CPR with a small chance of success is attempted in future, in spite of the burdens and risks, or they are sure that this is what the patient wanted, and it is your considered judgement that CPR would not be clinically appropriate and not of overall benefit for the patient, you should explore the reasons for the proxy’s request. If after further discussion you still consider that attempting CPR would not be of overall benefit for the patient, you are not obliged to offer to attempt CPR 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.

Resolving disagreements

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If there is disagreement about whether CPR should be provided, you should try to resolve it by following the guidance in paragraphs 47 - 49.

47

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.

48

If, having taken these steps, there is still significant disagreement, you should seek legal advice on applying to the appropriate statutory body for review (Scotland) or appropriate court for an independent ruling.22 The patient, those authorised to act for them and those close to them should be informed, as early as possible, of any decision to start such proceedings, so that they have the opportunity to participate or be represented.

49

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

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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 or advance care plan.36 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 it was your considered view that discussion with the patient was not appropriate, you should note this in the patient’s records.

36

See the guidance on recording and communicating decisions in paragraphs 75 - 77.

Treatment and care after a DNACPR decision

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You must make it clear to the healthcare team and, if appropriate, 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.

145

A DNACPR decision should not override your clinical judgement about CPR if the patient experiences cardiac or respiratory arrest from a reversible cause, such as the induction of anaesthesia during a planned procedure, or if the circumstances of the arrest are not those envisaged when the DNACPR decision was made.

Emergencies and CPR

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Emergencies can arise when there is no time to make a proper assessment of 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 you are certain you have sufficient information about the patient to judge that it will not be successful.