BMA, cardiopulmonary resuscitation (CPR), The British Medical Association (BMA), the Royal College of Nursing (RCN) and the Resuscitation Council (UK) are issuing new guidance today, Friday 26 October, on decisions about attempting to resuscitate patients when their hearts stop or if they stop breathing.
Health professionals are aware that decisions about cardiopulmonary resuscitation (CPR) can be very distressing for patients and people emotionally close to them. Today's guidance emphasises how important it is for doctors and nurses to be open and transparent about such decisions and provides advice about who should be consulted and informed when such decisions are made.
The new guidelines on CPR differ significantly from what is currently in place, for example: The Mental Capacity Act has been included to cover decision-making for patients who lack capacity, guidance is provided on who needs to be involved and what to do if there is disagreement between the clinical team and an appointed welfare attorney.
There is a much clearer distinction between decisions based solely on clinical factors (ie when the procedure will simply not work) and those based on a balance of benefits and burdens (ie an assessment of whether the benefits of providing CPR outweigh the potential risks).
There is more information about recording and communicating decisions. Currently the decision whether to resuscitate a patient may change when the patient leaves hospital in an ambulance to go home, to a hospice or to another hospital. For example, a decision may have been taken not to resuscitate because it would have been unsuccessful but this may not have been communicated to ambulance staff. The new guidance highlights the need for local policies that ensure good communication between all those involved, including hospitals, the ambulance service and primary care.
Clearer guidance is provided on who can make decisions about CPR. The new guidelines acknowledge that suitably experienced nurses may make decisions if local policy allows. Previously only consultants and GPs were able to make decisions about CPR.
Head of BMA Science and Ethics, Dr Vivienne Nathanson, said today:
"Doctors can find it difficult to discuss, either with a patient or their family, circumstances in which it may not be appropriate to attempt to re-start the patient's heart if it stops. However, the primary role of medicine is to benefit patients and when treatment can no longer achieve this, it is good practice to avoid further invasive and burdensome interventions.
She added: "In TV medical dramas CPR is often the wonder intervention that saves patients' lives and reunites them with their loved ones. Unfortunately, in real life the survival rate after a patient has a cardiac arrest and receives CPR is relatively low. CPR also carries the risk of internal fractures and ruptures and there is also a risk of long-term brain damage, amongst other things, again something that we rarely see on our TV screens. Health professionals need to be honest with patients about the likelihood and the level of recovery they can reasonably expect if CPR is attempted."
Dr Peter Carter, General Secretary of the Royal College of Nursing (RCN) said: "With clearer guidelines and better communication within the healthcare team, this guidance should help spare patients and their families the heartache and indignity of repeated and sometimes unnecessary resuscitation attempts. It will also mean that when a suitably experienced nurse believes that CPR will not be successful, they will be able to respond appropriately without having to wait for a GP or consultant.
"This joint guidance should reduce some of the traditional glitches in communicating resuscitation decisions across different sectors of the health service. It also recognises the important part that nurses play in decisions related to resuscitation and will allow experienced nurses to make key decisions in conjunction with their patients if appropriate."
Honorary Secretary of the Resuscitation Council (UK), Dr David Pitcher commented: "It is important to have a plan of treatment for people who are unwell, whether they are in hospital or in the community. For many people that plan should include a decision about whether or not to attempt resuscitation if their heart or breathing stops.
"The 2001 guidance on CPR was a major step forward as it made clear that these often-difficult decisions about resuscitation should be based on careful assessment of each individual, and emphasised the importance of involving patients in these decisions where CPR may be successful.
"Today's guidance re-emphasises these points but feedback and experience gained over the last six years have been used to clarify points that were causing continuing uncertainty. In particular the updated guidance states clearly that it is not always appropriate to distress a person who is dying, perhaps in the last few days of life, by discussing attempted resuscitation, when clearly CPR would not be successful."
Today's guidance will be available via the websites of all three organisations.