Chapter 12: Respiratory care, CPR and blood transfusion
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Clinical governance
Do Not Attempt Cardiopulmonary Resuscitation
The rate of survival after an in‐hospital cardiac arrest is still only in the region of 10%, depending on numerous factors, such as initial cardiac ECG (electrocardiogram) rhythm, co‐morbidities, age, performance status (a measure of the patient's activity level and performance), reason for hospital admission and cause of cardiac arrest (Findlay et al. [82], Meaney et al. [155], Nolan et al. [200]). To reduce the number of futile resuscitation attempts, many hospitals and organizations have introduced formal DNaCPR policies, which can be applied to individual patients in specific circumstances. Healthcare professionals must be able to show that their decisions relating to CPR are compatible with the Human Rights Act ([113]) as every person has the right to life, the right to be free from inhumane or degrading treatment, and freedom of expression (BMA et al. [23]). Where no such decision has been made and the wishes of the patient are unknown, CPR should be performed without delay (RCUK [232]).
The following guidelines are based on those provided in a joint statement by the British Medical Association, the Royal College of Nursing and the RCUK (BMA et al. [23]):
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An advance DNaCPR order should only be made after consideration of the likely clinical outcome, the patient's wishes and their human rights. Each individual case should take into consideration whether:
- attempting CPR would restart the patient's heart and breathing
- there would be no benefit to restarting the patient's heart and breathing
- the expected benefit is outweighed by the burdens (RCUK [232]).
- The clinician has a duty to discuss the decision with the patient, even if the discussion is likely to upset and distress the patient. The exception to this is if such a discussion is thought likely to cause the patient significant physical or psychological harm, in which case it may not be appropriate (BMA et al. [23]).
- Neither patients nor those close to them can demand treatment that is clinically inappropriate. If the healthcare team believes that CPR will not be successful, this should be explained to the patient in a sensitive way. Written information explaining CPR should be available for patients and those close to them to read. The aforementioned joint statement may help patients and their families to discuss DNaCPR with medical and nursing staff (BMA et al. [23]).
- Patients who are deemed to have metal capacity are entitled to refuse CPR even when there is a reasonable chance of success (Mental Capacity (Amended) Act [157]).
- The overall responsibility for decisions about CPR and DNaCPR orders rests with the consultant in charge of the patient's care. Issues should, however, be discussed with other members of the healthcare team, the patient and people close to the patient where appropriate.
- The most senior members of the medical and nursing team available should clearly document any decisions made about CPR in the patient's medical and nursing notes. The decision should be dated and the reasons for it given. This information must be communicated to all other relevant healthcare professionals (BMA et al. [23]). Unless it is against the wishes of the patient, their family should also be informed.
- The DNaCPR order should be reviewed on each admission and reconsidered if the patient's condition changes (BMA et al. [23]).
- Finally, it should be noted that a DNaCPR order applies only to CPR and should not reduce the standard of medical or nursing care (Moffat et al. [163]). Any reversible conditions identified should be treated as deemed appropriate.
Each hospital should audit all CPR attempts and assess what proportion of patients should have had a DNaCPR decision in place prior to the cardiac arrest and should not have undergone CPR, rather than have the decision made after the patient has arrested. This will improve future patient care by avoiding undignified and potentially harmful CPR attempts during the dying process (Findlay et al. [82]).
