Published 26 March 2009, doi:10.1136/bmj.b986
Cite this as: BMJ 2009;338:b986

Head to Head

Should hospices be exempt from following national cardiopulmonary resuscitation guidelines? No

¹ St Oswald’s Hospice, Newcastle Hospitals NHS Trust, Newcastle upon Tyne NE3 1EE, ² Northumberland Tyne and Wear NHS Trust, Newcastle upon Tyne, ³ Royal Bournemouth and Christchurch NHS Foundation Trust, Christchurch, Dorset

Cardiopulmonary resuscitation is traumatic and often unsuccessful in seriously ill patients. Max Watson and colleagues (doi:10.1136/bmj.b965) argue that current guidelines on its use are unsuitable for hospices, but Claud Regnard and Fiona Randall believe they ensure all patients get the best care

It is tempting to view hospices as unique therapeutic environments that demand special treatment. However, hospices have no desire to work outside national guidelines on good practice. The current cardiopulmonary resuscitation guidelines¹ uphold essential core principles and values that particularly apply in end of life care and are coherent with the Mental Capacity Act (England and Wales)^{2 3} and the Adults with Incapacity Act (Scotland),⁴ which govern decisions for patients who lack capacity. The guidelines reflect the good practice expected of hospices.

Protection against arbitrary discrimination

The guidelines provide essential protection against discrimination on irrelevant grounds. When a cardiorespiratory arrest is expected, and an advance decision is needed, the guidelines ensure this decision is tailored to the individual and to their circumstances, and not to arbitrary factors such as place of care.

When a cardiorespiratory arrest occurs unexpectedly, the guidelines state that there should be an initial presumption in favour of cardiopulmonary resuscitation unless the patient has a valid and applicable anticipatory decision refusing it. Therefore the new guidelines protect patients from arbitrary discrimination and protect their right to receive cardiopulmonary resuscitation.

They also promote a welcome return to common sense clinical practice by experienced clinicians. For example, a do not attempt resuscitation (DNAR) decision does not override clinical judgment if the patient has a reversible cause of arrest that does not match the circumstances envisaged in the decision (such as secretions blocking a tracheostomy tube). Hospice patients should not be exposed to unjust discrimination by policies that are inconsistent with the national guidelines (such as a default not to attempt cardiopulmonary resuscitation).

Protection of patient choice

When an arrest is expected and cardiopulmonary resuscitation has a realistic prospect of success, the guidelines require professionals to offer it even if they judge that the harms and risks might outweigh the benefits. Palliative care teams and services are increasingly caring for patients with life limiting illness other than cancer, and patients with life threatening cancer are living longer. In some of these patients cardiopulmonary resuscitation has a realistic prospect of success and should be attempted if the patient wants or would have wanted it. There is no justification for exempting hospices from offering cardiopulmonary resuscitation in this situation, even though their staff might provide only basic life support with an immediate call for appropriate emergency services.

The guidelines are equally protective of patients who have made a valid advance refusal of cardiopulmonary resuscitation, as required by UK law. The guidelines also make clear that both groups of patients (or their relatives if the patient lacks capacity) have the right to an informative discussion on cardiopulmonary resuscitation in their case. The protection of patient choice and effective communication of relevant information are cornerstones of effective hospice care. It makes no sense to seek exemption from guidelines that protect these rights.

Protection of patients who lack capacity and dying patients

The guidelines ensure that when the patient has lost capacity, either before or at the point of cardiorespiratory arrest, the decision regarding resuscitation will be determined by the patient’s best interests. Importantly for hospices the guidelines also protect patients from being subjected to cardiopulmonary resuscitation if there is no realistic prospect of success. Even if no prior decision has been made, the guidelines instruct that resuscitation should not be attempted or continued if it is clear that it could not be successful. In such patients the guidelines are clear that it is inappropriate to initiate a discussion about cardiopulmonary resuscitation. These safeguards are essential to prevent unnecessary distress for patients, partners, and relatives at the end of life.

Exemption equates with exclusion

Palliative care teams work in almost every clinical environment and setting. It is essential that these teams understand the ethical, legal, and clinical basis of cardiopulmonary resuscitation decisions. Working to different rules in hospices would result in confusion, exclude hospice patients from recognised good practice, and would seriously compromise working partnerships with colleagues in other settings. Exemption would create poorer, and thus inequitable, care for hospice patients.

In the UK, inpatient hospices either function under NHS regulations or are registered as independent hospitals under the regulations of the Commission for Social Care Inspection. Both bodies require hospices to have policies on cardiopulmonary resuscitation that follow the advice of the UK Resuscitation Council, currently expressed through the UK guidelines. The proposal that hospices should function outside the national guidelines is the antithesis of hospice aspirations to excellence of care, patient choice, equity, and to effective partnership with other specialties in all care settings. It is inconceivable that hospices should seek exemption from the good practice set out in the UK guidelines.

Main messages from UK guidelines1 Decisions must be made on the basis of an individual assessment of each patient’s case Advance care planning, including decisions about cardiopulmonary resuscitation, is an important part of good clinical care for those at risk of cardiorespiratory arrest Communication and the provision of information are essential parts of good quality care It is not necessary to start discussions about cardiopulmonary resuscitation with patients if there is no reason to believe that a patient is likely to suffer a cardiorespiratory arrest When no explicit decision has been made in advance there should be an initial presumption should be in favour of cardiopulmonary resuscitation If cardiopulmonary resuscitation would not restart the heart and breathing, it should not be attempted When the expected benefit of attempted resuscitation may be outweighed by the burdens, the patient’s informed views are of paramount importance. If the patient lacks capacity those close to the patient should be involved in discussions to explore the patient’s wishes, feelings, beliefs and values If a patient with capacity refuses cardiopulmonary resuscitation, or a patient lacking capacity has a valid and applicable advance decision refusing cardiopulmonary resuscitation, this should be respected A do not attempt resuscitation (DNAR) decision does not override clinical judgment in the unlikely event of a reversible cause of the patient’s respiratory or cardiac arrest that does not match the circumstances envisaged DNAR decisions apply only to cardiopulmonary resuscitation and not to any other aspects of treatment

Cite this as: BMJ 2009;338:b986

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Competing interests: FR and CR were unpaid advisers to the BMA on the 2007 joint statement on cardiopulmonary decisions.

References

1. 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. London: BMA, 2007.
2. UK Government. Mental Capacity Act 2005. London: Office of Public Sector Information, 2005.
3. Mental Capacity Act 2005: code of practice. London: Public Guardianship Office, 2007.
4. Scottish Parliament. Adults with Incapacity (Scotland) Act 2000. London: Office of Public Sector Information, 2000.

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