The British Medical Association (BMA), the Resuscitation Council (UK), and the Royal College of Nursing (RCN) have today (3o June) issued updated guidance regarding anticipatory decisions about whether or not to attempt resuscitation in a person when their heart stops or they stop breathing.
This update to the 3rd edition takes into account, in particular, the decision in the Winspear case, concerning the requirement to consult family members (or others properly concerned in the person’s welfare) where they do not have capacity to participate in the process leading to decisions made about CPR.
I reproduce below the main messages from the guidance, although cannot emphasise enough that they are not intended to be a substitute for reading the whole document and having regard to the clear and helpful flow-charts to assist decision-making.
1. Considering explicitly, and whenever possible making specific anticipatory decisions about, whether or not to attempt CPR is an important part of good-quality care for any person who is approaching the end of life and/or is at risk of cardiorespiratory arrest.
2. If cardiorespiratory arrest is not predicted or reasonably foreseeable in the current circumstances or treatment episode, it is not necessary to initiate discussion about CPR with patients.
3. For many people, anticipatory decisions about CPR are best made in the wider context of advance care planning, before a crisis necessitates a hurried decision in an emergency setting.
4. Every decision about CPR must be made on the basis of a careful assessment of each individual’s situation. These decisions should never be dictated by ‘blanket’ policies.
5. Each decision about CPR should be subject to review based on the person’s individual circumstances.
6. In the setting of an acute illness, review should be sufficiently frequent to allow a change of decision (in either direction) in response to the person’s clinical progress or lack thereof. In the setting of end-of-life care for a progressive, irreversible condition there may be little or no need for review of the decision.
7. Triggers for review should include any request from the patient or those close to them, any substantial change in the patient’s clinical condition or prognosis and transfer of the patient to a different location (including transfer within a healthcare establishment).
8. For a person in whom CPR may be successful, when a decision about future CPR is being considered there must be a presumption in favour of involvement of the person in the decision-making process. If she or he lacks capacity those close to them must be involved in discussions to explore the person’s wishes, feelings, beliefs and values in order to reach a ‘best interests’ decision. It is important to ensure that they understand that (in the absence of an applicable power of attorney or court-appointed deputy or guardian) they are not the final decision-makers, but they have an important role in helping the healthcare team to make a decision that is in the patient’s best interests.
9. If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable advance decision to refuse treatment (ADRT), specifically refusing CPR, this must be respected.
10. If the healthcare team is as certain as it can be that a person is dying as an inevitable result of underlying disease or a catastrophic health event, and CPR would not re-start the heart and breathing for a sustained period, CPR should not be attempted.
11. Even when CPR has no realistic prospect of success, there must be a presumption in favour of explaining the need and basis for a DNACPR decision to a patient, or to those close to a patient who lacks capacity. It is not necessary to obtain the consent of a patient or of those close to a patient to a decision not to attempt CPR that has no realistic prospect of success. The patient and those close to the patient do not have a right to demand treatment that is clinically inappropriate and healthcare professionals have no obligation to offer or deliver such treatment.
12. Where there is a clear clinical need for a DNACPR decision in a dying patient for whom CPR offers no realistic prospect of success, that decision should be made and explained to the patient and those close to the patient at the earliest practicable and appropriate opportunity.
13. Where a patient or those close to a patient disagree with a DNACPR decision a second opinion should be offered. Endorsement of a DNACPR decision by all members of a multidisciplinary team may avoid the need to offer a further opinion.
14. Effective communication is essential to ensure that decisions about CPR are made well and understood clearly by all those involved. There should be clear, accurate, honest and timely communication with the patient and (unless the patient has requested confidentiality) those close to the patient, including provision of information and checking their understanding of what has been explained to them. Agreeing broader goals of care with patients and those close to patients is an essential prerequisite to enabling each of them to understand decisions about CPR in context.
Speaking for myself, I do hope that this – very important – document is the last iteration of its kind before we can move beyond the fixation with DNACPR decisions into a broader approach to advance care planning: see in this regard the ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) project currently being undertaken by the Resuscitation Council (UK).