Analysis and Comment

Controversy

Cardiopulmonary resuscitation in continuing care settings: time for a rethink?

BMJ 2006; 332 doi: 10.1136/bmj.332.7539.479 (Published 23 February 2006)
Cite this as: BMJ 2006;332:479

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  1. Simon P Conroy, clinical lecturer in geriatrics (simon.conroy@nottingham.ac.uk)1,
  2. Tony Luxton, consultant community geriatrician2,
  3. Robert Dingwall, director3,
  4. Rowan H Harwood, consultant physician4,
  5. John R F Gladman, professor in medicine for older people1
  1. 1 Division of Rehabilitation and Ageing, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, NG7 2UH
  2. 2 Cambridge University Hospitals, Cambridge, CB1 3DF
  3. 3 Institute for the Study of Genetics, Biorisks and Society, University of Nottingham, Nottingham, NG7 2RD
  4. 4 Nottingham City Hospital, Nottingham, NG5 1PB
  1. Correspondence to: S P Conroy
  • Accepted 9 October 2005

Cardiopulmonary resuscitation is rarely successful in people who are old or frail, but current policy guidance fails to take this into account

The potential benefits of cardiopulmonary resuscitation, and the likelihood of failure or adverse effects, are not the same for everyone. Current NHS guidelines require staff to involve patients and their families in resuscitation decisions in accordance with local policies.1 2 However, strict application of these guidelines to people in continuing care settings (such as care homes or community hospitals) potentially diverts staff time and resources away from core elements of care, for limited benefit. We question whether it is ethically appropriate to require all institutions to provide resuscitation.

Current position

Current guidelines apply to NHS and other establishments including hospitals, general practices, and residential care homes. The guidelines recognise that cardiopulmonary resuscitation is not always appropriate and that, when it is, some patients will refuse it. However, all institutions are required to have a policy on resuscitation and should provide cardiopulmonary resuscitation unless an overt decision has been made to the contrary.

Rates of survival

Acute hospitals

The patients most likely to survive cardiopulmonary resuscitation (30% survival to discharge) are monitored patients with ventricular tachyarrhythmias,3 but the overall rate of survival to discharge in acute hospitals is about 14%.3–5 One third to one half of survivors will have new, moderate to severe functional or neurological impairment3 6 w1-w3 as defined by the Glasgow-Pittsburgh cerebral performance categories.7 The patients with the best chances have minimal comorbidity, receive prompt defibrillation, and the shortest period of resuscitation.6

Public places

Cardiopulmonary resuscitation in public places such as airports and supermarkets, in particular using automatic external defibrillators, is sometimes successful. The recipient is likely to have been previously fit, or at least ambulant.8 Typical rates for survival to discharge are 5-10%.w4-w13 Of …

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