I often chat with my work colleagues and ask them the searching question, ‘Have you thought about how and where you would prefer to die?’
I am surprised that most of them haven’t even thought about their own death, or what their personal preference is. This alarms me, considering the amount of death we actually deal with in our line of work!
For my own part, should I be suffering from an incurable illness, I will be instructing my GP and get my own DNAR written out, and I will leave it in a big white envelope just by the front door - in the hope that the young, keen ambulance crew who come rushing in will take note, and leave me to die in the peace I hopefully have earned!
APPENDIX III
Should patients at the end of life be given the option of receiving CPR?
by Madeline Bass, BSc, RGN, Head of Education, St Nicholas Hospice, Bury St Edmunds, Suffolk
First published in Nursing Times; 105 4, 26-02-2009.
Cardio-pulmonary resuscitation (CPR) is often unsuccessful and may not always be appropriate at the end of life. This article debates whether the use of cardio-pulmonary resuscitation by healthcare professionals in situations when it is unlikely to be successful feeds an unhealthy appetite to intervene just because it is possible. It explores the problem of offering patients and relatives the choice about CPR at the end of life when it is likely to be unsuccessful.
End-of-life and palliative care has become an increasingly important area of healthcare professionals’ work following publication of the End of Life Care Strategy (Department of Health, 2008).
Good communication between patients and staff is essential for those who are making choices and decisions about care at the end of life. This may include discussions about cardio-pulmonary resuscitation.
We can now treat disease and disability in ways that would not have been thought possible sixty years ago. These achievements have also created bioethical dilemmas. The advent of new treatment interventions has brought its own unhealthy appetite - the more treatments healthcare workers have to offer, the more they intervene. To them, this equates with doing the best for patients and knowing that everything has been tried.
However, in some cases, interventions can mean poor outcomes for the patient and result in low staff morale. One area of particular concern is the decision about when it is appropriate to perform CPR.
Misconceptions about CPR
The media’s interpretation of CPR, primarily through TV drama, has led to a misunderstanding that it is a quick intervention that guarantees success without any side-effects (Bass, 2003; Diem et al, 1996).
CPR was first used in its present advanced life-support format of chest compressions, ventilation and defibrillation in i960 (Kouwenhoven et al, 1960). The main problem associated with CPR is identifying when it is appropriate to instigate it as a life-saving measure. The concern is that the decision to proceed is often viewed as the default if a decision about resuscitation has not been made.
CPR was devised as an emergency intervention for unexpected cardiac or respiratory arrest (Kouwenhoven et al, i960) and the majority of healthcare professionals are not aware that the success rates for CPR are very low (Wagg et al, 1995; Miller et al, 1993) (see Table 1). Only a small percentage of people will survive to leave hospital following a cardiac or respiratory arrest.
Ewer et al (2001) looked at the success rates of CPR undertaken on patients with cancer. They asked whether patients were expected to have an irreversible cardiac or respiratory arrest. The results showed that, of patients having an unexpected, reversible arrest, there was a 22.2% success rate. However, for those who were expected to have an irreversible arrest and were at the end of life, there was 0% success.
The effects of inappropriate CPR are often not considered. These include post-resuscitation disease (complications caused by resuscitation itself) (Negovsky and Gurvitch, 1995), an undignified death for the patient, and distress to relatives. Paramedics and resuscitation teams may also become demoralised by repeated failures (Jevon, 1999).
Table 1. Success rates for CPR
Factors influencing success of CPR
The success of CPR is often measured in terms of initial success - the return of heartbeat and breathing, controlled independently by the patient. It is also measured in terms of survival to discharge (see Table 1). The chances of successful CPR are improved if
There is early access to a cardiac arrest team
Basic life support is commenced immediately
Defibrillation is carried out as quickly as possible in cases of ventricular tachycardia or pulseless ventricular fibrillation (Jevon, 2002).
Other positive factors associated with a successful CPR attempt include:
A non-cancer diagnosis
Cancer without metastases
The patient is not housebound
Good renal function
No known infection
Blood pressure within normal range
The patient has robust health (Newman, 2002).
The Gold Standard Framework (GSF) suggests that cancer, organ failure, general frailty and dementia are not associated with success (NHS End of Life Programme, 2007).
The BMA et al (2007) recommended that CPR should not be attempted when patients have indicated before the cardiac arrest that they would refuse it or if the attempt is likely to be futile because of their medical condition.
Resuscitation decisions
Discussions about resuscitation at the end of life raise a number of questions.
Are public expectations of healthcare and technology unrealistic?
Do healthcare professionals pursue the possibility of an immediate positive outcome from CPR without considering the long-term consequences of the intervention?
Does inappropriate CPR raise false hope in patients, relatives and staff? (Jevon, 1999)
Awareness and knowledge of CPR guidance among healthcare professionals is poor (Bass, 2003), with knowledge focusing on local policy rather than research evidence and national guidance.
In addition, healthcare professionals often fail to recognise when a patient is dying, which can result in difficulty making an appropriate decision about whether to resuscitate in the event of a cardiac or respiratory arrest. The Liverpool Care Pathway (LCP) is a recommended national tool that can assist professionals to make an accurate diagnosis of dying (Ellershaw and Ward, 2003). This diagnosis can help to inform discussion about when to initiate CPR.
Reducing the inappropriate use of CPR
The inappropriate use of CPR can be reduced by improving communication between all members of the multidisciplinary team. The End of Life Care Strategy (DH, 2008) gives guidance and outcomes for care at the end of life, including dignity, appropriate care and comfort – appropriate care should include refraining from undertaking inappropriate CPR.
The Mental Capacity Act 2005 allows patients to make advance care plans and allows them to have choices at the end of life. If they are to support patients in making such plans, healthcare professionals need to discuss appropriate choices with them.
It is good practice to have a local Do Not Attempt Resuscitation (DNAR) policy, and use the documentation from the GSF for patients in their own home. The framework prompts healthcare professionals to initiate discussions around advance care planning, such as about what patients want at the end of their life and whether they have choices.
The GSF also encourages healthcare professionals to ask the question: ‘Would I be surprised if this person died in one year/one month/one week/one day?’ The patient is coded and specific guidance for this coding is given. The coding is:
A: prognosis of years
B: prognosis of months
C: prognosis of weeks
D: prognosis of days.
Guidance relating to the coding provides information about what professionals should discuss with patients and care that should be planned and provided.
For example, if a patient is in the last few weeks of life, then drugs suc
h as analgesics should be available in the person’s home in case they are needed. This can prevent a crisis if these drugs are required at short notice. Depending on the patient’s condition, the coding is reviewed regularly to take into account any changes.
The majority of GP practices in England have now adopted the GSF in some format, but how it is adopted and adapted depends on individual GP practices.
Choice and misconceptions about CPR
Patient choice is high on the health and social care agenda (Department of Health 2008; 1991; Mental Capacity Act 2005) but this can lead to patients being offered unrealistic choices that are not supported by expert professional opinion. The wrong choice can result in a negative outcome for the patient.
In my experience, there is a misconception among some nurses, doctors and patients that all patients/carers should be given a choice about resuscitation.
Many nurses will have experience of doctors entering a patient’s room when they are in the last few days of life and asking the family carers: ‘If your relative’s heart and lungs stop working, do you want us to resuscitate them?’ In some situations, the family carers are adamant that they do not want this. However, where death is approaching much more quickly than expected, or when it has been difficult for family carers to accept their relative’s approaching death, they may decide that they want CPR.
This can leave healthcare professionals with an ethical dilemma – the family carers want everything to be done, but CPR itself is not an appropriate intervention, so what should they do when the patient dies? The choice is to initiate CPR or to risk a complaint and possible litigation if they do not.
CPR guidance from the BMA et al (2007) does not help healthcare professionals with this dilemma. It states that if patients insist they want CPR, even if it is deemed to be futile, it should be carried out but, when an arrest occurs, the situation should be reviewed. In reality, this means that the patient is offered an intervention that will not be given. This does not support a trusting relationship between healthcare professionals and the patient (Bass, 2008).
Patients or family carers cannot demand CPR and healthcare professionals are not required by law to give a futile treatment. So why is CPR offered at the end of their life when other interventions, such as surgery, would not be considered?
The National Council for Palliative Care (2002a) states that: ‘There is no ethical obligation to discuss CPR with the majority of patients receiving palliative care for whom such treatment, following assessment, is judged futile.’
Written guidance on how to decide if someone is appropriate for CPR has been developed by Randall and Regnard (2005). They produced a flow chart that asks whether the person is expected to have a cardiac or respiratory arrest from a reversible or irreversible cause. If the cause is reversible and there is a chance that CPR would be successful, the patient should be asked whether they would or would not like it, should they go into cardiac or respiratory arrest. If the cause is irreversible and there is no chance of success from CPR, then it should not be offered.
Practice points
End-of-life care does not have to be complex.
Patients and family carers need to be kept informed about care plans.
Keep the treatment plan simple by only offering interventions that are appropriate for that individual as this is less confusing.
CPR should not be offered when it is deemed to be futile.
Involve the multidisciplinary team in discussions about end of life.
If your place of work does not have a Do Not Attempt Resuscitation (DNAR) policy, it is important to highlight this. All staff should also be aware of the BMA et al (2007) resuscitation guidelines. The National Council for Palliative Care (2002b) has published a document that offers guidance on how to write a local DNAR policy. If you work for an NHS trust, always consult your local policy and guidelines group.
If there is a chance of successful CPR, then the intervention should be discussed with the patient. If the patient does not have capacity, then evidence of advance care planning, either written or verbal, should be sought. If there is no evidence of either, the patient’s representatives should be asked what they think the patient would want. Alternatively, an independent mental capacity adviser (IMCA) or a court of protection decision may be required.
If CPR is not going to be successful, it should not be offered. The aims of care should be discussed with the patient.
Implications for practice
I would argue that nurses are not equipped through basic training to deal with the stress and psychological trauma that patients and family carers are dealing with at the end of life. Nurses develop these skills through experience, reflection and self-awareness. Nurses can support those who are at the end of life by:
Refining their communications skills
Offering appropriate interventions
Checking the patient understands what is happening
Using appropriate terminology.
Good communication skills
Good communication includes active listening – this is hearing what is said as well as paying attention to what is communicated in non-verbal ways such as body language.
It is not possible to guess how someone will feel about CPR as there are huge discrepancies between what we think patients want and what they actually want (Jevon, 1999).
We need to make sure that patients and families understand that saying no to CPR does not mean they are saying no to all interventions.
Offering appropriate interventions
Treatment interventions that are unlikely to be successful should not be offered.
The CPR guidelines state that each resuscitation decision should be discussed, where appropriate, with the individual or their representative (BMA et al, 2007). However, ‘discussion’ does not necessarily mean asking the patient or family to make a decision. Discussion may involve talking things over, finding out what the person’s understanding of the current situation is, and outlining the treatment aims (Bass, 2006). This can be achieved by asking the question, ‘What is your understanding of what has been happening to you/your relative up to now?’ Alternative questions such as ‘Are you the sort of person who likes to know what is going on?’ can be helpful.
These questions may show that the patient understands much more than first thought, or that they would rather you discussed interventions with someone else, for example their family or carers.
Check the patient’s understanding
Patients may have heard what has been said but have not retained the information. They may have difficulty taking in what has been said either because they cannot believe it, or they do not understand the terminology used. It is important to check a patient’s understanding and provide written information if appropriate to reinforce what has been said.
Using appropriate terminology
It may not be appropriate to use the term ‘resuscitation’ when discussing end-of-life care with patients. Simple phrases stating that at the time of death you will not attempt ‘anything heroic’, but will ‘do all we can to make sure you are comfortable’, are extremely useful.
Conclusion
By making sure we communicate well, and by using tools such as the GSF, LCPI, DNAR policies and advance care planning documentation, nurses can ensure that they are supporting their patients at the end of life.
Awareness of when CPR is appropriate and careful assessment and care planning by the multidisciplinary team will ensure that patients are only offered interventions that are beneficial.
References
Bass, M. (2008) Resuscitation: knowing whether it is right or wrong. European Journal of Palliative Care; 15:4, 175-178.
Bass, M. (2006) Palliative Care Resuscitation. Chichester: John Wiley and Sons.
Bass, M. (2003) Oncology nurses’ perceptions of their role in resuscitation decisions. Professional Nurse; 18:12, 710-713.
British Medical Association, Resuscitation Council (UK), RCN (2007) Deci
sions relating to Cardiopulmonary Resuscitation. A joint statement from the British Medical Association, the Resuscitation Council UK and the Royal College of Nursing. London: BMA, RCUK, RCN.
Department of Health (2008) End of Life Care Strategy. London: DH.
Department of Health (1991) The Patient’s Charter. London: DH.
Diem, S J et al. (1996) Cardiopulmonary resuscitation on television. New England Journal of Medicine; 334: 24, 1758-1582.
Ellershaw, J, Ward, C. (2003) Care of the dying patient; the last hours or days of life. British Medical Journal; 326: 7374, 30-34.
Ewer, M S et al. (2001) Characteristics of cardiac arrest in cancer patients as a predictor of survival after CPR. Cancer; 92: 7, 1905- 1912.
NHS End of Life Programme (2007) Prognostic Indicator Guidance.
Jevon, P. (2002) Advanced Cardiac Life Support: A Practical Guide. Oxford: Butterworth Heinemann.
Jevon, P. (1999) Do not resuscitate orders: the issues. Nursing Standard; 13: 40, 45-46.
Karetzky, PEet al. (1995) Cardiopulmonary resuscitation in intensive care unit and non-intensive care patients. Archives of Internal Medicine; 155: 12, 1277-1280.
Kouwenhoven, W B et al. (i960) Closed chest cardiac compressions. Journal of the American Medical Association; 173: 1064-1067.
McGrath, R B. (1987) In-house cardiopulmonary resuscitation after a quarter of a century. Annals of American Medicine; 16: 12, 1365-1368.
Miller, DLet al. (1993) Factors influencing physicians in recommending in-hospital cardiopulmonary resuscitation. Archives of Internal Medicine; 153: 17, 1999-2003.
National Council for Palliative Care (2002a) Ethical Decision-making in Palliative Care. London: NCPC.
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