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HEAD TO HEAD: Claud Regnard and Fiona Randall Should hospices be exempt from following national cardiopulmonary resuscitation guidelines? No BMJ 2009; 338: b986 [Full text]

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Offer of CPR undermines hospice philosophy

Don C Aston, Shirley, Solihull B90 2BG   (28 March 2009)

Informing the debate: How common is a sudden and unexpected death in a specialist palliative care unit?

Andrew Wilcock, Vincent Crosby   (19 May 2009)

Exemption of hospice from national CPR guidelines is not necessary.

Alexander Spiers   (24 May 2009)

Offer of CPR undermines hospice philosophy 28 March 2009
Don C Aston, Retired 34, Burman Road, Shirley, Solihull B90 2BG Send response to journal: Re: Offer of CPR undermines hospice philosophy	Hospices surely stress that they promote `natural ` death seeking neither to accelerate nor postpone it? Any offer of CPR surely conflicts with this principle and in fact some hospices require patients admitted even just for symptom control to acknowledge in writing that it will not be available. And from a more practical point of view the authors will be well aware of the enormous pressure on beds in usually very small hospices particularly away from the south-east where as few as 2% of all deaths may take place in them. To the extent that CPR is ` successful` in postponing inevitable death otherwise qualifying terminally-ill patients may have to be turned away and more hospice patients may have to be transferred to nursing homes right at the end of their lives if they do not die exactly when expected. They may well be too heavily sedated by then to be aware what is happening to them but this does not apply to their relatives. Other people have rights apart from the particular hospice patients being cared for at any one time - this is particularly relevant for hospices still heavily dependent on private donations from large numbers of supporters. Competing interests: None declared
Informing the debate: How common is a sudden and unexpected death in a specialist palliative care unit? 19 May 2009
Andrew Wilcock, Reader in Palliative Medicine & Medical Oncology Hayward House Macmillan Specialist Palliative Care Unit, Nottingham University Hospitals NHS Trust, Vincent Crosby Send response to journal: Re: Informing the debate: How common is a sudden and unexpected death in a specialist palliative care unit?	Data on the mode of death of patients in specialist palliative care units or hospices would help to inform discussions around cardiopulmonary resuscitation (CPR).[1,2] Because we were unable to find any such data we recently undertook a survey in our 20-bed specialist palliative care unit. The mode of death of 100 consecutive deaths were categorised by attendees of the weekly multidisciplinary team meeting as either ‘gradual and expected’ - an expected death preceded by a gradual (several days-weeks) terminal decline; ‘sudden but expected’ - an expected death, preceded by a rapid (1–2 days) decline; or ‘sudden and unexpected’ - an unexpected death with little or no warning. The categories were pragmatic, based on clinical experience, with ‘sudden and unexpected’ considered most likely to reflect the circumstances requiring an instant decision on whether to commence or withhold CPR. The use of the care of the dying pathway was noted as an additional indicator of an expected death. All patients had cancer and the deaths represented half of the 197 admissions over a period of 24 weeks. Five deaths were sudden and unexpected, with none on the care of the dying pathway (Table). One was immediately preceded by chest pain and shortness of breath, raising the possibility of a pulmonary embolism or cardiac event (patient 1); the remainder were found dead in bed. None had any history of cardiac disease. All had a documented decision not to attempt CPR as it was unlikely to be successful, based on individual assessments of the presence of advanced incurable cancer ± poor performance status. Our sample is small and there is a lack of comparable data. However, a sudden and unexpected death was not that uncommon. Nonetheless, most were not witnessed by staff and in none was CPR considered appropriate. Although blanket policies which determine CPR status on admission have been criticised, our data suggests that even within a specialist palliative care unit, having a definite decision could potentially save ‘instant’ decisions having to be made by various disciplines and grades, perhaps some relatively junior or inexperienced. A definite decision should reduce the risk of inappropriate attempts at CPR and, conversely, ensure CPR is not withheld when it is appropriate. The latter may become more relevant as specialist palliative care is increasingly involved with patients at an earlier stage and with diagnoses other than cancer. 1. Regnard C, Randall F. Should hospices be exempt from following national cardiopulmonary resuscitation guidelines? No. BMJ 2009;338:b986 2. Watson M, McPherson A, Murray SA. Should hospices be exempt from following national cardiopulmonary resuscitation guidelines? Yes. BMJ 2009;338:b965. Competing interests: None declared
Exemption of hospice from national CPR guidelines is not necessary. 24 May 2009
Alexander Spiers, Professor of Medicine (retired). SL6 9TR Send response to journal: Re: Exemption of hospice from national CPR guidelines is not necessary.	In 1976, when I went to work in the United States, to provide or not to provide CPR was a very vexed question. One viewpoint was that not to provide CPR might be construed as malpractice and lead to a lawsuit. Another, incorrect, was that there was a legal necessity to provide CPR. Some physicians, principally Catholic, felt that there were ethical and religious objections to withholding CPR. In some institutions it was virtually impossible to die without first undergoing CPR. I witnessed CPR being applied to patients with terminal cancer who had declined over a long period and then died. Fortunately, such misplaced efforts were very seldom successful, but they were costly, time-taking, and an assault upon the dignity of the patients. Eventually the legal situation was clarified and it was established that there was no obligation to provide futile treatment. A similar conclusion was reached by most medical ethicists. In a great many hospitals, a DNR (do not resuscitate) order could be written after consultation with the patient, or with their representative in the case of comatose or otherwise incompetent patients. It is notable that extremely few very ill patients refused to have a DNR order written. Some institutions became overenthusiastic and even asked well patients who were undergoing minor surgery or even childbirth if they wished to have a DNR order written. Fortunately this foolish custom did not become entrenched. In hospice practice, a DNR order was virtually a routine procedure upon admission. Very few patients wished to undergo CPR, even if death was sudden and unexpected, because they were tired of their chronic and progressive illness and wished to die. Some patients insisted upon the withdrawal of any measures that might prolong their lives, even treatment as innocuous as tamoxifen in advanced breast cancer. So long as a DNR order is permitted, and so long as patients are fully consulted as to their wishes, there is no necessity to exempt hospices from national guidelines on the provision of CPR. Clinical judgment and respect for the wishes of patients offer sufficient protection for the terminally ill. Competing interests: None declared