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Introduction

Although Mrs Conti's condition has been stabilised, she is still very weak and her prognosis is poor - she could suffer an arrest at any time. Mrs Conti begins asking to go home and her family support her request. Dr Ellis is talking to Nurse Bhogal about the practicalities of attempting cardiopulmonary resuscitation (CPR).

(The story so far...)

Mrs Conti, who is 80, has been diagnosed with heart failure. There has recently been a deterioration in her condition, and she was admitted to hospital because she was having difficult breathing.

Staff Nurse Bhogal

Nurse Bhogal

I've spoken to the rest of the team, and we're all agreed that CPR should not be attempted if Mrs Conti arrests. But we need to get it noted down in the right place, and we must talk to her son and daughter-in-law. They're on the ward now, if you want a word.

Dr Ellis

Dr Ellis

But...surely we should talk to Mrs Conti herself first? Though it's true I'm not entirely happy about raising the subject with her at this stage: why trouble her with a long and upsetting discussion about a procedure that's unlikely to be successful? She's getting less and less inclined to discuss her situation generally...it's such an effort for her to talk. And she's adamant that she just wants to go home.

Staff Nurse Bhogal

Nurse Bhogal

We should talk to the family as well, though. Otherwise if she has a cardiac arrest at home, they'd call an ambulance and the crew would have to try to resuscitate her. That would be very distressing for everyone and, if she isn't successfully resuscitated, it's hardly the dignified death that one would hope for. Wouldn't it be best to put a "Do Not Attempt CPR" order in her records? We'd discuss it with the family of course, but that way she can die peacefully at home when the time comes.

What should the doctor do...? (Select A,B or C)

A

Speak to Mrs Conti and explain why it has been decided not to attempt CPR if she suffered a cardiac arrest?

B

Decide that it would be inappropriate to burden Mrs Conti with information about the Do Not Attempt CPR direction in her records but explain the decision to Mrs Conti's son and daughter-in-law?

C

Speak to Mrs Conti alone, and gently raise the subject of CPR, to try and establish whether she is willing to talk about it?

Dr Ellis

See what the doctor did

"Mrs Conti was reluctant to engage in discussion with Dr Ellis about CPR, or much else about her condition, and asked that her son deal with everything from now on. With Mrs Conti's agreement secured, Dr Ellis took Mrs Conti's son and daughter-in-law aside and explained the DNACPR decision. Although upset, they understood the reasons behind it, and felt that this would be helpful in ensuring that Mrs Conti had a peaceful death at home. Dr Ellis recorded the DNACPR decision in Mrs Conti's notes and also arranged for her GP and out-of-hours doctor services to be informed."

References

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.

(Treatment and care towards the end of life: good practice in decision-making, paragraph 129)

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.

(Treatment and care towards the end of life: good practice in decision-making, paragraphs 134 - 135)

14. There may be circumstances in which you decide not to share all relevant information with a patient straight away. If you delay sharing information necessary for making a decision, you should let the patient know there's more to discuss and make sure arrangements are made to share the information as soon as it's appropriate to do so. You must make a record of the information you still need to share, your reasons for not sharing it now, and when it can be shared.

15. You should not withhold information a patient needs to make a decision for any other reason, including if someone close to the patient asks you to. In very exceptional circumstances you may feel that sharing information with a patient would cause them serious harm and, if so, it may be appropriate to withhold it. In this context 'serious harm' means more than that the patient might become upset, decide to refuse treatment, or choose an alternative. This is a limited exception and you should seek legal advice if you are considering withholding information from a patient.

65. No one else can make a decision on behalf of an adult who has capacity. If a patient who has capacity asks you or someone else to make a decision on their behalf, you should tell them this. You should explain that it's important they understand some basic information so that you can proceed with treatment or care. This would usually include what the options are and what they aim to achieve.

66. If a patient has chosen an option but doesn't want to discuss the details, you should explain they will need to have some information about what it would involve before you can proceed, such as:

a. whether the procedure is invasive
b. what level of pain or discomfort they might experience and what can be done to minimise this
c. anything they should do to prepare for the intervention
d. if it involves any risk of serious harm.

67. You should try to find out why they don't want to be involved in decision making and explore whether you can do anything to reassure and support them. They might be anxious about the decision or overwhelmed by the information and need time or support to process it.

68. If, after trying to discuss options with them along the lines set out above, your patient insists that they don't want even this basic information, you will need to judge whether their consent is valid so that you can proceed. This is more likely to be the case if the proposed option is a well-established intervention commonly used for treating the condition they have, and there's reason to believe the patient wants to be treated or cared for rather than take no action. You should consider seeking advice from your medical defence body or professional association in these circumstances.

(Decision making and consent, paragraphs 14-18 and 65-68)