The nature of healthcare means that, sometimes, difficult conversations have to take place in hospitals between doctor and patient.
Here, Dr Jim Crawfurd, an A & E Consultant with more than 15 years’ experience, answers some of the key questions around Cardio Pulmonary Resuscitation (CPR), a procedure used to attempt to re-start a patient’s heart when it stops beating.
He explains why it is important to have conversations about CPR with patients as early as possible, why the procedure is not suitable for everyone - and seeks to dispel some of the myths surrounding it.
CPR should be seen as a massive assault on a person’s body that should only be used when there is a realistic possibility of restoring that person to an acceptable quality of life. The procedure involves vigorous chest compressions that often result in broken ribs; putting a tube into the lungs to artificially breathe for the patient; delivering large doses of adrenaline and other drugs; and also sending powerful electric shocks to the heart.
The majority of people’s experience of CPR is seeing actors carry it out in an episode of a medical drama series. Is this a realistic portrayal?
In terms of survival rate, the answer is no. TV dramas paint an overly-positive picture – with a 60% survival rate. The reality is different: national statistics show that just 20% survive and go on to leave hospital in a relatively good state. This percentage decreases with age and frailty – and, if you are already in hospital with a serious condition and your condition deteriorates to such an extent that you have a cardiac arrest, the chances of CPR being successful are virtually zero. It should also be noted that even if a CPR procedure is successful, the patient can be left with impairments to heart, lung and brain function. The portrayal of CPR on TV tends to make it look less unpleasant and shorter than it is in real life – CPR attempts can go on for 30 minutes or more, with the chances of a successful outcome declining as the resuscitation attempt gets longer.
CPR was developed in the 1960s as a treatment for young (40-60yr old) patients who had suffered a heart attack, were on Coronary Care Units and suddenly developed fatal disturbances of the heart’s rhythm. In those circumstances, CPR is still an effective treatment, with around a 60% survival rate. Over the last 50 years, it has been increasingly used outside of that setting, with very variable success. If we use it on the right patients, it gives around 1 in 5 of them the chance of surviving to discharge from hospital, mostly with a reasonable quality of life. However in many patients, it stands virtually no chance of success. The challenge for us as doctors and patients is to make sure that it is offered to those who would stand to benefit from it, but not carried out on those who would not benefit from it.
Firstly, it is important to note how things have changed in recent years. Historically, a decision about CPR was made purely on medical grounds, with no requirement for the doctor to inform or discuss the decision with the patient or the patient’s family. Now, there is a legal requirement for doctors to inform patients of DNA CPR decisions, unless doing so would cause actual harm to the patient. The courts have been clear that we cannot avoid discussion purely because it might upset a patient or relative.
Secondly, if there is a chance, however slim, that CPR might work on a patient, then it is up to the patient to make a decision on whether the procedure should be performed, based on information given by the doctor.
Finally, if it is clear that CPR would not work, the doctor needs to explain to the patient why it would not work and make it clear that we would not offer them CPR in the event of a cardiac arrest.
They can ask for a second opinion. If the patient disagrees with the second opinion, which happens extremely rarely, the matter is referred to the Medical Director for a third opinion.
Not necessarily. A degree of common sense is applied. They should always take place if someone is brought into hospital with a serious injury or illness and is felt to be at risk of cardiac arrest during this admission.
However, in straight forward cases, where the risk is low, and medically there is no reason not to try CPR, then the conversation is not required. For example, there is no need to have the conversation with a young healthy patient who comes in with appendicitis. However, a note would be made on their notes that CPR would take place in the event of a cardiac arrest.
It must be stressed that if a patient, whatever their condition, has decided that they do not want CPR and have the capacity to make such a decision, then the doctors treating them will take this into consideration.
Well, as already stated, if we are considering a DNACPR decision, there is a legal requirement to speak to the patient (or those close to the patient if the patient is unable to participate in the discussion). But it is far more than that.
These can be difficult conversations for the patient, their family and the doctors and medical staff. But they are conversations that must happen, for the benefit of everyone, with the aim of reaching a consensus.
The logic of having the conversation is to give the patient realistic information and then allow them, where appropriate, to make their own choice – and for that choice to be recorded.
If the conversation doesn’t take place, then the default is to perform CPR if the patient has a cardiac arrest, which can have devastating consequences. “Cardiac arrest” simply means that the heart has stopped – it is a part of every death. Imagine how traumatic it would be for a family gathered around a hospital bed to hold the hand of a desperately ill loved one as they peacefully slip away – only to have a hospital ‘crash’ team suddenly descend on them to perform an unnecessary and ultimately unsuccessful CPR procedure. A conversation in advance can stop this type of situation and allow the patient to die with dignity.
All acute hospitals must have a cardiac arrest (‘crash’) team on site 24/7. All clinical staff are trained in basic life support but the crash team comprises five senior members of medical staff.
It is important to remember that cardiac arrest team staff are not sitting around, waiting for a call to perform CPR. They are senior staff who are busy in the hospital, tending to patients’ needs. When they are called upon, they have to leave their duties for up to an hour to deal with a CPR attempt. This takes them away from other patients, increasing their risk – so CPR decisions should not be taken lightly.
When a decision is made in advance that a patient will not be resuscitated in the event of cardiac arrest, does this mean that all other active health treatment is then withdrawn?
Absolutely not. The decision applies solely to the process of CPR in the event of a cardiac arrest. It has no bearing on any other form of treatment. Put simply, it means that when you are ill, we will do all we can to help you recover. But if your heart stops in spite of this care, we will not try to start it again.
If a patient loses capacity, the responsibility for making any decisions around CPR lies with medical staff. We are obliged to discuss with the family what they think the patient would want - but we need to make it clear that we are NOT asking them to make a decision. We are taking responsibility for the decision and we want them to understand and agree with the decision. The exception to this is if a patient has made an Advance Directive that covers CPR, or has a legally appointed Healthcare Power of Attorney – in these situations the Advance Directive or LPA can make the decision on behalf of the patient.
Yes. It is based on national guidance from the Resuscitation Council (UK). It is regularly updated and is available to the public through the Trust’s website, in the documents at the bottom of our Strategies & Policies page here.
Yes. I would like them to actively think about it, and bring it up with their GPs, doctors or nurses. We need to de-mystify CPR and have sensible, informed conversations about it, so that each patient can reach a decision that is right for themselves.
Dr Jim Crawfurd, A&E Consultant