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Case study 1

This case study explores issues arising from decisions about cardiopulmonary resuscitation (CPR).

Please note

The case studies are fictional and for illustration purposes only.

They do not represent GMC guidance or policy in themselves, nor are they intended to replace Treatment and care towards the end of life: good practice in decision making (2010) or any other GMC guidance.

All paragraph numbers highlighted in this case study refer to the GMC's guidance Treatment and care towards the end of life: good practice in decision making (2010). You can download the guidance here (469 kb, pdf) for reference.

Part 1

Mr Alan Bruce is 42 and a self employed electrician. He has a partner, Donna, and two teenage children. He has recently been diagnosed with prostate cancer with bone metastases following investigations for back pain. 

His disease initially responded to hormone therapy but a repeat bone scan shows clear disease progression. He accepts the offer of palliative (non-curative) chemotherapy to be given in three cycles to improve his symptoms, because he wants to keep going as long as possible.

After the first cycle, the chemotherapy is put on hold as he experiences severe nausea and vomiting. Just as the nausea and vomiting is starting to settle, Mr Bruce develops a chest infection. 

His GP visits and starts oral antibiotics. Mr Bruce has sudden onset chest pain after a bout of prolonged coughing and takes several doses of his usual pain medication. But then his partner discovers him slumped in a chair barely breathing. 

Donna phones the ambulance. In the Emergency Department they conclude that his breathing difficulties result from the sensitivity he has developed to his pain medication - he is given treatment to reverse this effect - and he is admitted to the intensive care unit (ITU) with severe pneumonia.

After 24 hours of ventilation and IV antibiotics Mr Bruce is improving; he’s waiting for a bed on the medical ward. His ITU consultant, Dr Douglas, reviews his medical history and investigations which show that he has a rib fracture and cancer deposits in several other ribs. 

She discusses with the ITU nursing and medical team that there is a significant risk that Mr Bruce could suffer a cardiac or respiratory arrest; this might be reversible if it were due to the effect of his pain medication on his breathing; however the new information about the cancer deposits in his ribs meant that CPR carried a clear risk of significant harm to Mr Bruce. 

If his heart stopped for any reason attempting CPR would be likely to have significant and severe side effects. They agree there’s a need to consider making a DNACPR decision.

Mr Bruce is improving – how should the ITU team decide if this is a decision that they need to discuss with him?  

  • What are the likely benefits, burdens and risks of CPR for Mr Bruce?
    (Paragraphs 24-25, 40-42, 128-131, 133 of the guidance)

  • What is Mr Bruce’s understanding and expectations about his condition and the likely course of his disease?
    (Paragraphs 28, 132-133)

The team agree that it is uncertain whether CPR would work, but the likelihood is that CPR, if successful, would result in rib fractures and would possibly result in a flail chest, punctured lung, ruptured spleen or liver and therefore significant morbidity for Mr Bruce. 

It would be helpful to know Mr Bruce’s views, but they are also concerned about raising the issues with him at this stage.

What factors do the team need to consider?

  • Might he be willing to discuss, in general terms, his wishes about end of life care?
    (Paragraphs 52-55,137-138)

  • Can there be realistic discussion about the physical nature of CPR treatment and the likely clinical and other outcomes in his case, or would this need to be approached gradually? 
    (Paragraphs 55-58, 138-139)

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