The resuscitation conversation

Conversations about cardiopulmonary resuscitation (CPR) at the end of life can be extremely difficult. Many people’s perception of CPR is influenced by TV scenes, where it is almost always successful and people recover swiftly. Here are five things to think about when opening up this conversation.

1)  Starting these conversations early allows patients time to think about what they want and perhaps discuss options with their families. In the case of a dementia diagnosis it should be done as soon as possible to allow the patient to make choices about their care.

2)  It is never appropriate to ask ‘Do you want to have CPR?’ Instead, ask the patient's preferences around the question: "Under what circumstances might you want to refuse CPR?’

3)  Explain to the patient that although CPR can sometimes be effective when a person's heart and breathing stops prematurely (eg: when choking); in their circumstances their heart and breathing will stop because they have reached the natural end of their life. 

4)  Explain gently that CPR can be incredibly traumatic and invasive. Dignity is a key issue for most people and explaining what CPR entails allows them to exercise control over their care. Make it clear that they will still receive other treatments and care for their condition. 

5)  If the person chooses to complete an advance decision to refuse treatment (ADRT) with you, explain to them the importance of communicating their preferences to their loved ones and carers, otherwise these preferences may not be carried out if they are unable to communicate at a later stage. 

Do not Attempt Cardiopulmonary Resuscitation (DNACPR)

The chance of survival following cardiopulmonary resuscitation (CPR) in adults is between 5-20% depending on the circumstances. Although CPR can be attempted on anyone, there comes a time for some people when it is not in their best interests to do this. It may then be appropriate to consider making a Do Not Attempt CPR (DNACPR) decision to enable the person to die with dignity.

A DNACPR decision is a clinical one based on the patient's best interests, but it is important that the patient and relatives (if the patient is happy for them to be included) are involved at an early stage. This ensures that the decision made by the GP is understood in the context of the realities of CPR outside of the view perpetuated through the media, which is that CPR is nearly always successful. Allowing this open communication will ensure that the decision is understood with a mutual consensus being reached. If the patient has strong views regarding resuscitation then the GP should encourage them to complete an ADRT to ensure that this is communicated and give the patient piece of mind.
 
It is important that any DNACPR decisions are communicated to every healthcare professional who will be involved in the patient's care to ensure that no inappropriate attempts at CPR are made. This can be achieved through the Electronic Palliative Care Coordination System (EPaCCS) or using Message in a Bottle. It is important that the patient, or their carers, are made aware that the DNACPR form remains the patient's property and should therefore be taken with them when they visit any medical institution or organisation to ensure communication to all healthcare professionals. 

What you will achieve

Improved outcomes for patients and carers will help your professional development and increase your learning credits. Reducing inappropriate admissions and interventions is an important outcome measure for CCGs 

Links to available resources

• NEW Information about DNACPR: www.endoflifecare.nhs.uk/dnacpr
• Dying Matters offers a range of leaflets to help with conversations, planning and bereavement support: www.dyingmatters.org
• The National Council for Palliative Care (NCPC) offers a range of guidance and training materials for those delivering end of life care, including comprehensive guidance on the   Mental Capacity Act: www.ncpc.org.uk
• The National End of Life Care Programme works with health and social care staff, providers, commissioners and third sector organisations across England to improve end of life care for adults: www.endoflifecareforadults.nhs.uk

A range of practical support is available for GPs, including:

• Planning your Future Care outlines many of the issues to consider: Download the leaflet
• Information about Lasting Power of Attorney: www.direct.gov.uk
• Information about DNACPR:www.endoflifecare.nhs.uk/dnacpr
• Information about advance decisions to refuse treatment: www.adrt.nhs.uk
• A training DVD to increase the confidence of GPs in initiating conversations with patients at the end of life: CPD accredited e-learning modules: www.e-lfh.org.uk/projects/e-elca
• Communications skills resources: www.endoflifecareforadults.nhs.uk
• Support on implementing the national end of life care information standard and electronic palliative care co-ordination systems: www.endoflifecareforadults.nhs.uk
• Route to success resources, including hospitals and care homes: www.endoflifecareforadults.nhs.uk/tools/core-tools/rtsresourcepage
• LEAFLET FOR PATIENTS - Your Guide to Decisions About Cardiopulmonary Resuscitation (CPR): Download the PDF

Ref 1) Meaney PA et al.  Rhythms and outcomes of adult in-hospital cardiac arrest.  Crit Care Med 2010; 38(1):101-8.

Ref 2) Perkins GD, Cooke MW.  Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators.  Emerg Med J 2012; 29(1):3-5.