Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Important decision
- Nabeela Nisar (5 November 2007)
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Right decision, wrong reasons
- Deborah Bird (7 November 2007)
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Good practise but who is in charge?
- James E Griffin (7 November 2007)
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All of the above...plus
- Teresa T. Goodell,RN,PhD (10 November 2007)
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A Nurse Trained In CPR Can Reduce Mortality
- Robert James, Akashdeep Singh (16 November 2007)
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Deficits in Professional and Public Knowledge of Resuscitation Matters
- John D Groarke, Joseph Gallagher and Rory McGovern (21 November 2007)
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DNR is a matter of opinion
- M R S Siddiqui (18 August 2008)
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Nabeela Nisar, GP trainee Whipps cross Hospital
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Of course the nurses should be included in Cardiopulmonary Resuscitation decisions because it will provide experienced advice regarding the decision. It will help other members of the team be more involved in the decision which would in turn help in dealing with the patient's family in a better way and will improve team work in the unit. It might bring to light aspects and implications of the decision that might not have been previously thought of because the nurses will be seeing things from a slightly different prespective Competing interests: None declared |
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Deborah Bird, Specialist Registrar in Paediatrics Medway Maritime Hospital, ME7 5NY
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Whilst I agree in principle that nurses should be able to undertake an end-of-life discussion, I strongly disagree with the quoted reasons for this change. Vivienne Nathamson is quoted as saying "Doctors often find it difficult to discuss, either with a patient or their family, circumstances in which it may not be appropriate to attempt to restart the patient's heart if it stops". Agreed, these discussions are difficult, perhaps even more so in paediatrics, but they are an essential part of a doctors role. To suggest that nurses take over this role when doctors find it too difficult is ridiculous. Similarly, Peter Carter is quoted as saying that nurses should be able to undertake the discussion without a doctor because it would allow experienced nurses to "respond appropriately without having to wait for a GP or a consultant." The suggestion that nurses should be included simply because it takes too long for the doctor to get there is insulting to nurses and inappropriate. An experienced nurse is a valuable asset in his/her own right, not just as a substitute for the busy or frightened doctor. Let's embrace the involvement of nurses in these discussions, but please can we do it for the right reasons. Competing interests: None declared |
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James E Griffin, SpR Haematology Bristol Haematology and Ocology Centre
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I definitely support nurses involvement in resuscitation decisions. I have worked on teams where nursing staff would always be involved before a not for resuscitation decision was made and if they were not in agreement then the patient would remain for resuscitation. I have also worked for consultants who will not make patients not for resuscitation. What will happen if the consultant responsible for a patient wishes them to remain for resuscitation but a senior nurse feels that they should not be for resuscitation? Other doctors may agree with the nurses decision but in the end I would want clarification as to who would have the final say. Competing interests: None declared |
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Teresa T. Goodell,RN,PhD, clinical nurse specialist, assist. professor Or. Health & Science Univ., Portland, OR USA 97239
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I would like to add a U.S. advanced practice nurse's viewpoint. Of course nurses ought to be involved in resuscitation decisions. Nurses are often the health care providers spending the most time with the patient and family. The need for improved communication of patient wishes is urgent. We must ask, discuss and educate those we serve much more consistently, frequently, and accurately than we are now doing. However, at least in my practice, physicians often actively resist discussion of foregoing resuscitation or providing palliative care. The attitudes of physicians must change to allow these discussions to take place without engendering a sense of failure on the part of the physician, which drives reluctance to bring up end-of-life and comfort care. To put it bluntly: it's not about you, doctors. It's about the patient and family. They need this difficult discussion, whether you like it or not. My essay on this topic is available at this address for those interested: http://www.cancerlynx.com/failure.html Competing interests: None declared |
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Robert James, MD Medicine Christian Medical College and Hospital, Ldh, Pb, In, Akashdeep Singh
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Nurses should be involved in decision making regarding cardio pulmonary resuscitation. Infact they should be the ones who know it properly. Nurse on duty is one of the first ones who attends a sick patient in casualty department. She is one of the first who assesses the patient, gathers vital information about the patient, checks vital signs and so detects a patient in crisis who might require a CPR. A nurse’s duty usually is in one ward for a long time and she has the experience of working with various consultants and junior doctors on rotatory posting. Hence she knows exactly when to interveine and what all medications would be required and when to administer them, and thus saves precious time. A good CPR should be started immediately; there are three minutes to secure airway, breathing and circulation should be secured within three minutes of stoppage of spontaneous cardiac and respiratory activity. A doctor might not be available always immediately, he might be busy attending another patient. So if the nurse is trained to execute a successful CPR and if she has the right to take crucial decisions, then precious time can be saved and also mortality can be reduced. In many cases a busy ward or ICU might be left under supervision of a junior doctor, and in the event of a cardiac arrest an experienced staff in the ward can be a big boost to morale and help save a life. Competing interests: None declared |
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John D Groarke, Specialist Registrar General Internal Medicine St. Luke's General Hospital, Kilkenny, Ireland., Joseph Gallagher and Rory McGovern
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Dear Editor, The recently published UK guidance on decisions relating to cardiopulmonary resuscitation extends resuscitation decision making to ‘suitably experienced nurses’. Recently, we undertook a survey of doctors, nurses and the general public to examine their understanding of specific aspects of resuscitation. The findings revealed deficits in basic resuscitation knowledge among all groups. 30 doctors, 25 nurses (84% having five or more years nursing experience)and 30 general public were randomly selected and interviewed. Estimates of survival to discharge varied considerably among the three groups, with only 70% doctors, 24% nurses and 0% of public correctly estimating survival to discharge following in-hospital resuscitation attempts. The remaining percentages of each group overestimated survival. Our study highlighted confusion among health professionals surrounding boundaries between best practice, ethical guidelines and law. For example, 47% of doctors and 40% of nurses incorrectly believe that decisions on resuscitation made by a doctor in the best interest of an adult patient lacking capacity without discussion with the patients' family are invalid. In the setting of intra-family disagreement regarding the resuscitation status of an adult relative lacking capacity, 30% of doctors and 29% of nurses incorrectly believe that the final decision rests with the majority rule of the family rather than with the relevant senior clinician. All nurses and 13% of doctors interviewed incorrectly believe that a patient’s advance directive demanding a resuscitation attempt is binding on medical staff. Senior decision makers must be able to differentiate between following best practice and actual points of law. Furthermore, the general public demonstrated a poor understanding of the exact nature of resuscitation attempts and of terms used in resuscitation discussions. For example, 67% of those interviewed equate a cardiac arrest to a ‘heart attack’ and 58% believe a Do Not Attempt Resuscitation order will result in cessation of all forms of treatment for a patient. Our ethical guidelines often conflict with public opinion – 40% believe that the final say on the resuscitation status of an incompetent adult relative rests with the family. Given the lack of knowledge among healthcare professionals and the general public regarding resuscitation, it would seem wise to tackle this knowledge deficit before considering any change in guidelines. Training in ethics, communication and outcomes of resuscitation is needed among healthcare staff. Better support and information is needed for patients and their families faced with resuscitation decisions. Perhaps before introducing an extension of resuscitation decision making powers we might equally consider fewer people making better informed decisions, whether these be doctors or nurses or preferably the patient themselves. JD Groarke, J Gallagher, R McGovern. Department of Medicine, St. Luke's General Hospital, Kilkenny Competing interests: None declared |
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M R S Siddiqui, Surgical Registrar BN11 2DH
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Guidance on DNR orders is necessary, however the implementations of that guidance is subject to how people percieve them. Whilst experience is undoubtedly important when making these decisions, knowledge of potential remedial treatments and interventions are paramount. Whilst I advocate the involvement of nursing staff, (not necessarily experienced or inexperienced), it is important not to forget that these decisions must be combined with clear academic and clinical reasons. If a decision is to be made it must be made by someone in charge who possesses all those qualities and I believe only a consultant or senior GP has them. Another problem is narrowing oneself to this issue when infact the implications are much more far reaching. Doctors are often reluctant to implement the DNR order because staff equate it to a reduced level of care where iv fluids and antibiotics are felt to be inappropriate(An audit of nurses’ views on DNR decisions - British Journal of Nursing Vol. 14, Iss. 20, 09 Nov 2005, pp 1061 - 1065 ). I would urge those who are considering DNR orders to leave the final decision to consultants and senior GPS; this is not an issue of the professions (nurses vs doctors) and not even necessarily of who is the most qualified but one of being unalienably unable to interpret guidelines in an absolute way; and hence the less people making the final decision the better. Competing interests: None declared |
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