Introduction
“Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation for a person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest). ” Medical Dictionary. In some patients it is an intervention that can provide precious extended life. However, in other patients it may be unlikely to work and could result in the patient having an undignified, traumatic death. Therefore, it is important that CPR decisions and decisions related to treatment in the event of clinical deterioration are discussed proactively.
Discussing Plans for Treatment in the Event of Clinical Deterioration
The NHS manages over 1 million patients every 36 hours (https://www.nhsconfed.org/resources/key-statistics-on-the-nhs). The majority of these patients do not require a documented plan for treatment in the event of clinical deterioration, but for patients at risk of cardiorespiratory arrest a plan for treatment in the event of clinical deterioration ought to be made.
The plan for treatment in the event of clinical deterioration should be made by the senior clinician who has clinical responsibility for the patient. It is a plan made in the best interest of the patient, guided by information and views acquired from the patient and/ or relevant others.
To make a plan for treatment in the event of clinical deterioration the clinician should ensure that they establish the patient’s and/ or relevant others’ understanding of the patient’s:
They should also clarify the patient’s:
During this conversation it is imperative that the clinician provides the patient and/or relevant others with information about the advantages and disadvantages regarding these matters. They must also ensure that they answer any questions the patient and/or relevant others have and provide reassurance to support the decision.
Discussing this plan is a delicate matter that if approached insensitively can cause anger, distress and resentment. It is important that the discussion is held at the right place, at the right time and with the right people present.
After making a plan for treatment in the event of clinical deterioration, the clinician should document (ReSPECT guidance):
This information may be recorded on a special form such as the ReSPECT form (Recommended Summary Plan for Emergency Care and Treatment) or Do Not Attempt Cardiopulmonary Resuscitation form (DNACPR). This allows the information to be accessible and easily recognisable by the multi-professional team.
Communication
Good communication surrounding the plan for treatment in the event of clinical deterioration is vital to make sure the patient receives high-quality, patient centred, and fare care. Communication must occur between the lead senior clinician and the patient and/ or relevant others, as mentioned earlier, but it must also occur within the multi professional team involved in the patient’s care. This is to ensure the recommendations are known by all members of the team and that they will be used as a guide to treatment.
Deciding whether or not to attempt CPR
The bedside decision of whether to attempt or not attempt CPR should be made following a review of benefits and burden to the patient, the clinical picture and, if available, the plan for treatment in the event of clinical deterioration. Forms included in the plan for treatment in the event of clinical deterioration, such as the ReSPECT form or DNACPR, are not legally binding and are intended solely as a guide to aid the team in making the best possible immediate decision (ReSPECT guidance).
Whether or not to attempt CPR at the time of a cardiorespiratory arrest requires an immediate decision by the team present. With every minute that passes without CPR and defibrillation, the chances of survival decrease by 7–10%. (Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model. AnnEmergMed. 1993;22:1652–1658.)
In some cases, the patient may be dying following the progression of their incurable disease or following a catastrophic event. In this case starting CPR would not be of overall benefit to the patient and would likely be unsuccessful. Therefore, initiating CPR would not be advised. In other cases, the picture may not be as clear-cut. The patient may have a complicated history but nothing likely to drastically shorten their life expectancy or a plan for treatment in the event of clinical deterioration may not have been made and the team may be unaware of the patients’ individual priorities and preferences regarding their treatment. In such cases, it is presumed that the team will start CPR and make all reasonable effort to resuscitate the patient.
Deciding to stop CPR
According to the National Cardiac Arrest Audit (2015) of the in-hospital cardiac arrests during the daytime on a weekday, just 26% of patients survived to leave hospital. This shows that in a large number of cases CPR is not successful and at some point, a decision must be made to stop CPR.
A decision to stop may be made following more information becoming available on the patient’s baseline health status, their clinical picture on admission, the expected outcome of the admission or the plan for treatment in the event of clinical deterioration. In general, CPR is continued whilst the patient is in a shockable rhythm and whilst reversible causes for cardiac arrest continue.
The decision to stop CPR should be made by the lead clinician involved in the resuscitation attempt and it should be made following discussion with the team.
Special circumstances
In patients who are hypothermic at the time of cardiac arrest, CPR should be attempted using the modified advanced life support algorithm (Advanced Life Support Seventh Addition Resuscitation Council (UK)). These patients have a much higher chance of return of spontaneous circulation without neurological damage. Therefore, CPR should be continued until the patient has been rewarmed to normal temperature.