Cardiac arrest month: Is it always appropriate to prolong life?

Blurred ambulance

Prolonging a life usually provides a health benefit to that person. But when it is not appropriate to do so at all costs? Advanced decisions to refuse treatment, and DNACPR, are difficult subjects.

Though we try to save life wherever possible, sometimes it’s not appropriate to prolong life at all costs with no regard to its quality, or to the potential harms and burdens of treatment. Instead, the decision to treat should be based on the balance of risks and benefits to the individual receiving the treatment.

In this article, Patient Safety Officer Ant Brett explores this principle which applies to any treatment, including CPR.

So what is it?

An Advanced Decision to Refuse Treatment (ADRT), or living will, is a process involving the patient and their relevant healthcare professionals, whereby the patient can express preferences or wishes about their future care. This can involve refusing specific care and appointing a Lasting Power of Attorney (LPoA) to allow someone else to make care decisions when they are no longer able to themselves.

The purpose of a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) order is to offer guidance to health care professionals on when to, and when not to, start resuscitating a patient in cardiac arrest.

What does it mean and when will one be issued?

Where people are known to have a chronic illness (e.g. cancer or advanced heart failure) the realities of successful treatment or CPR should be discussed. A full clinical assessment documenting the chances of a successful outcome from resuscitation should take place. Where possible, this should be completed and discussed with the patient and hospital doctors or a GP ahead of the last few weeks, or days, of life. Advanced care planning allows each person to choose what interventions, including CPR, they wish to receive when their health deteriorates, whether that is due to progression of a known condition or an unexpected secondary illness or injury.

A DNACPR applies specifically to CPR - all other appropriate treatment and care for that person should continue. It is important this is understood by healthcare professionals and made clear to patients and those close to them. It is a common fear amongst members of the public that DNACPR applies to all elements of treatment.

How does this apply to us?

Problems have arisen in the past because CPR decisions were not communicated or accepted as valid by ambulance services. The national Clinical Practice Guidelines state that in the presence of cardiac arrest, CPR should always be commenced, unless a patient has a condition unequivocally associated with death.

The guidelines also state that resuscitation can be discontinued where there is a DNACPR order or ADRT that states the wish of the patient not to undergo attempted resuscitation, or where death is imminent and CPR would not be successful.

It goes without saying that it can be a complicated issue, and there are many myths and misconceptions around DNACPRs, so back in June we shared a Q&A for colleagues to help clarify what our roles and responsibilities are. It answers questions around photocopied forms, expiry dates, and tricky topics like what to do if you’re with an end-of-life patient with no DNACPR form.

The Q&A was created from discussions with frontline staff and those with an active interest in end-of-life care – download a copy internally from East24, or contact the communications team to have a copy emailed to you.

Ant Brett

Patient Safety Officer

Published 11th November, 2016

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