Published 26 March 2009, doi:10.1136/bmj.b965
Cite this as: BMJ 2009;338:b965

Head to Head

Should hospices be exempt from following national cardiopulmonary resuscitation guidelines? Yes

¹ Northern Ireland Hospice, Belfast, BT15 3LH, ² University of Ulster, Coleraine, Ireland, ³ Northern Ireland Palliative Medicine Training Scheme, ⁴ Primary Palliative Care Research Group, Division of Community Health Sciences: General Practice Section, University of Edinburgh.

Cardiopulmonary resuscitation is traumatic and often unsuccessful in seriously ill patients. Max Watson and colleagues argue that current guidelines on its use are unsuitable for hospices, but Claud Regnard and Fiona Randall (doi:10.1136/bmj.b986) believe they ensure all patients get the best care

The patient population in UK hospices is changing. Patients with malignant and non-malignant diseases, increasing disease complexity, and multiple comorbidities are attending from earlier in their illness for management of symptoms and supportive care. Indeed, almost half of hospice patients are now discharged.¹ Yet, despite these trends we must remember that hospice patients have illnesses that are not curable.²

Hospices should be exempt from applying blanket national cardiopulmonary resuscitation guidelines³ because the needs and treatment goals of hospice patients differ from those of patients in other care settings. Instead, the hospice movement should develop its own guidelines, which would take account of patients close to death as well those admitted for symptom control and rehabilitation.

Problems with existing guidelines

The joint statement from the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing on cardiopulmonary resuscitation¹ is a helpful step forward but translates disappointingly into the hospice sector. It is not written for, and applies poorly to, the hospice population, where the goal for the majority is quality of life and a dignified death.

In the context of hospices, it is important to clarify the differences between cardiopulmonary arrest and dying (table). Cardiopulmonary arrest is a medical emergency, with potentially reversible causes. Dying, however, is an irreversible natural process in which cardiopulmonary resuscitation has no chance of success. It may not always be easy to distinguish one from the other, but failure to do so can cause major distress for all involved. If a patient is dying, resuscitation is inappropriate. Discussion of resuscitation with such patients is unnecessary and confusing.

View this table: [in this window] [in a new window]   Differences between dying and cardiopulmonary arrest

 
Rather than following the national recommendations that patients can opt out of cardiopulmonary resuscitation, it would be more appropriate for hospices to have a policy of opting in. Although some people may feel this leaves hospices open to the charge of "giving up" on patients, the minimal likelihood of a patient being discharged after successful resuscitation makes such a stance more sensible and sensitive.

The guidelines make no reference to the clinical decision that is most likely positively to affect the outcome for hospice patients requiring cardiopulmonary resuscitation—that is, if the risk of needing resuscitation increases, whether it would be appropriate to transfer them to an acute hospital that has the facilities to maximise the chances of preventing cardiopulmonary arrest or for full resuscitation. Sometimes patients at high risk of arrest are not transferred because, even after full explanation, they choose not to leave the hospice or they are already getting maximum appropriate therapy, or they are too unwell to transfer. In these cases resuscitation is clearly inappropriate.

Considered approach

The guidelines also leave important questions unanswered—for example, how you weigh up the benefits versus the risks and make a valid assessment of the likelihood of success in patients who have no possibility of cure. More research is needed to answer these questions, but in the meantime any guideline on decisions about cardiopulmonary resuscitation in hospices must highlight at least two key issues.

Firstly, as in the current national guideline, it should emphasise that cardiopulmonary resuscitation describes only attempts to achieve return of spontaneous circulation. It does not refer to the treatment of any other life threatening conditions such as anaphylaxis, or to decisions concerning hydration, nutrition, or antibiotics. Thus decisions around cardiopulmonary resuscitation should be seen in the context of a medical emergency and not end of life decisions. Equally a do not attempt resuscitation order does not apply to any decisions except those relating to cardiopulmonary resuscitation¹; such an order does not mean do nothing.

Secondly, the guideline must encourage timely and appropriate discussion with patients to ascertain their wishes. This is always good practice, but it seems disingenuous to ask patients whether they want cardiopulmonary resuscitation if full facilities are not available. In reality many hospices offer something similar to that currently available in a supermarket or an airport (basic life support while awaiting a cardiac ambulance), though often without the defibrillator. True respect for patient autonomy requires that discussions about these issues take place before patients enter the hospice system.

Decisions about cardiopulmonary resuscitation are often complex, challenging, and emotive. The context of the decision making is key. One national policy for all healthcare contexts is too ambitious. A specific hospice guideline that is clear, simple, and robust, with accompanying implementation training for staff, needs to be developed as a priority.

Cite this as: BMJ 2009;338:b965

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Competing interests: None declared.

References

1. National Council for Palliative Care. National survey of patient activity data for specialist palliative care services: MDS full report for the year 2006-2007. www.ncpc.org.uk/download/mds/MDS_Full_Report_0607part.pdf.
2. Twycross R, ed. Introducing palliative care. 4th ed: Radcliffe Medical Press, 2003.
3. British Medical Association, Resuscitation Council UK, Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation: a joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. 2007. www.resus.org.uk/pages/DNAR.htm.

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