A new BMA/RCN/RC resuscitation guideline was published this week (accessible here, link at bottom of press release). It incorporates the recent Janet Tracey judgment, in which a person’s (human) right to be involved in their own resuscitation decision was affirmed. Deprivation of this right by doctors acting unilaterally and without appropriate discussion is now illegal. The guideline anticipates the situation that many of us feared, following the judgment, in which illness, circumstance and time do not allow such a discussion (either with the patient or with close relatives), and offers reassurance to doctors that if they are sure resuscitation would not work, there is no obligation to try. In this area I found the document very clear and helpful.
However… what caught my eye was an apparent easing of the pressure on clinicians to engage in DNACPR discussions.
The first step in the decision tree looks like this:
What does ‘clear possibility’ mean? Manifest cardiac instability? Severe illness? Anyone coming into hospital can suffer an arrest, so one must look to the text for more guidance here. The relevant paragraph in the summary is…
- 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.
This seems to go against the philosophy of identifying very frail patients on post-take rounds or early following admission, and having the discussion ‘just in case’. Most arrests are unpredictable and unforeseeable – otherwise we wouldn’t let them happen, or we would warn our patients and let them prepare for death (or for dramatic life-saving interventions). I find this sentence troubling. It wonder if it will take the ‘heat off’ clinicians on their ward rounds. Currently I encourage colleagues to consider engaging in DNACPR discussions if patients are very frail or have end-stage disease, even if they are not obviously deteriorating in front of their eyes. This guidance seems to undermine such a pro-active approach.
Further on in the text (pages 7 and 8) this area is explored in more detail. This detail makes me wonder if I have misunderstood the algorithm.
– There is no ethical or legal requirement to initiate discussion about CPR with patients, or with those close to patients who lack capacity, if the risk of cardiorespiratory arrest is considered low.
That sounds reasonable.
– In some cases there is an identiﬁable risk of cardiac or respiratory arrest, either because of an underlying incurable condition (such as cancer or advanced heart failure), because of the person’s medical history (such as myocardial infarction or stroke), or current clinical condition (such as overwhelming sepsis).
This suggests that end stage disease is a risk for cardiac arrest, and is a flag that should prompt the clinician to discuss DNACPR. The patient with COPD requiring home oxygen who is admitted moderately unwell with an infective exacerbation might fulfil this criteria, although a diffident clinician reading the algorithm (and paragraph 2 in the summary) might well conclude that there is nothing in the clinical situation to suggest a ‘foreseeable’ arrest.
We read further…
– If there is a risk of cardiac or respiratory arrest, it is important to make decisions about CPR in advance whenever possible. There should be a full clinical assessment of the chances of a successful outcome.
Nevertheless it is crucial that an anticipatory decision about CPR is considered when a person is at risk of death or cardiorespiratory arrest. In a hospital setting, appropriate triggers to consider or review a decision about CPR include an unplanned or acute admission to hospital, improvement or deterioration in the person’s clinical condition during hospital treatment (especially but not exclusively deterioration requiring review by an ICU outreach team), or transfer to a different clinical team or care environment (e.g. change of ward).
Now this seems to justify my own tendency to at least consider a DNACPR discussion after admission to hospital, even if the severity of the acute situation does not suggest that death will occur in the next few days. But it appears to contradict what came before.
So, to conclude – I find this document helpful in many ways, but somewhat confusing and unsupportive of the general trend which is to be brave in engaging our patients in discussion. Most doctors would agree that we do not talk about dying enough. Although we do not wish to drag our patients into difficult, surprising or unheralded conversations (when the reason for admission is relatively trivial, for instance), hospitalisation does represent an opportunity to at least consider the uncertainties that progressive disease brings.
From my reading of this document, clinicians who find the whole area difficult and distasteful may feel justified in retreating from it at the first hurdle.