Cardiopulmonary resuscitation decisions should be extended to nurses
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39384.681829.DB (Published 01 November 2007) Cite this as: BMJ 2007;335:901
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
DNR is a matter of opinion
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
Competing interests: No competing interests