Jennifer Worth - In the Midst of Life

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.

Patient choice is high on the health and social care agenda (Department of Health 2008; 1991; Mental Capacity Act 2005) but this can lead to patients being offered unrealistic choices that are not supported by expert professional opinion. The wrong choice can result in a negative outcome for the patient.

In my experience, there is a misconception among some nurses, doctors and patients that all patients/carers should be given a choice about resuscitation.

Many nurses will have experience of doctors entering a patient’s room when they are in the last few days of life and asking the family carers: ‘If your relative’s heart and lungs stop working, do you want us to resuscitate them?’ In some situations, the family carers are adamant that they do not want this. However, where death is approaching much more quickly than expected, or when it has been difficult for family carers to accept their relative’s approaching death, they may decide that they want CPR.

This can leave healthcare professionals with an ethical dilemma – the family carers want everything to be done, but CPR itself is not an appropriate intervention, so what should they do when the patient dies? The choice is to initiate CPR or to risk a complaint and possible litigation if they do not.

CPR guidance from the BMA et al (2007) does not help healthcare professionals with this dilemma. It states that if patients insist they want CPR, even if it is deemed to be futile, it should be carried out but, when an arrest occurs, the situation should be reviewed. In reality, this means that the patient is offered an intervention that will not be given. This does not support a trusting relationship between healthcare professionals and the patient (Bass, 2008).

Patients or family carers cannot demand CPR and healthcare professionals are not required by law to give a futile treatment. So why is CPR offered at the end of their life when other interventions, such as surgery, would not be considered?

The National Council for Palliative Care (2002a) states that: ‘There is no ethical obligation to discuss CPR with the majority of patients receiving palliative care for whom such treatment, following assessment, is judged futile.’

Written guidance on how to decide if someone is appropriate for CPR has been developed by Randall and Regnard (2005). They produced a flow chart that asks whether the person is expected to have a cardiac or respiratory arrest from a reversible or irreversible cause. If the cause is reversible and there is a chance that CPR would be successful, the patient should be asked whether they would or would not like it, should they go into cardiac or respiratory arrest. If the cause is irreversible and there is no chance of success from CPR, then it should not be offered.

End-of-life care does not have to be complex.

Patients and family carers need to be kept informed about care plans.

Keep the treatment plan simple by only offering interventions that are appropriate for that individual as this is less confusing.

CPR should not be offered when it is deemed to be futile.

Involve the multidisciplinary team in discussions about end of life.

If your place of work does not have a Do Not Attempt Resuscitation (DNAR) policy, it is important to highlight this. All staff should also be aware of the BMA et al (2007) resuscitation guidelines. The National Council for Palliative Care (2002b) has published a document that offers guidance on how to write a local DNAR policy. If you work for an NHS trust, always consult your local policy and guidelines group.

If there is a chance of successful CPR, then the intervention should be discussed with the patient. If the patient does not have capacity, then evidence of advance care planning, either written or verbal, should be sought. If there is no evidence of either, the patient’s representatives should be asked what they think the patient would want. Alternatively, an independent mental capacity adviser (IMCA) or a court of protection decision may be required.

If CPR is not going to be successful, it should not be offered. The aims of care should be discussed with the patient.

I would argue that nurses are not equipped through basic training to deal with the stress and psychological trauma that patients and family carers are dealing with at the end of life. Nurses develop these skills through experience, reflection and self-awareness. Nurses can support those who are at the end of life by:

Refining their communications skills

Offering appropriate interventions

Checking the patient understands what is happening

Using appropriate terminology.

Good communication includes active listening – this is hearing what is said as well as paying attention to what is communicated in non-verbal ways such as body language.

It is not possible to guess how someone will feel about CPR as there are huge discrepancies between what we think patients want and what they actually want (Jevon, 1999).

We need to make sure that patients and families understand that saying no to CPR does not mean they are saying no to all interventions.