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.
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
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.
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.
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 such 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.