Letters Hospices and CPR guidelines

Sudden and unexpected death in a palliative care unit

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2343 (Published 09 June 2009) Cite this as: BMJ 2009;338:b2343
  1. Andrew Wilcock, Macmillan reader in palliative medicine and medical oncology1,
  2. Vincent Crosby, consultant physician1
  1. 1Hayward House Macmillan Specialist Palliative Care Unit, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham NG5 1PB
  1. andrew.wilcock{at}nottingham.ac.uk

    The mode of death in specialist palliative care units or hospices could inform discussions on cardiopulmonary resuscitation (CPR).1 2 We recently analysed 100 consecutive deaths in our 20 bed unit. All patients had cancer, and the deaths represented half of the 197 admissions over 24 weeks. Mode of death was categorised pragmatically at weekly multidisciplinary team meetings as 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). Sudden and unexpected deaths were considered most likely to require an instant decision on whether to start or withhold CPR. The use of the care of the dying pathway was noted as an additional indicator of an expected death.

    In all, 84 deaths were gradual and expected with all but one patient on the care of the dying pathway; 11 deaths were sudden but expected with none of the patients on the pathway; and five deaths were sudden and unexpected, with none on the pathway. The sudden and unexpected death in case 1 (table) was immediately preceded by chest pain and shortness of breath, raising the possibility of a pulmonary embolism or cardiac event; the remainder were found dead in bed. None had any history of heart disease. All had a documented decision not to attempt CPR as it was unlikely to be successful on the basis of individual assessments of the presence of advanced incurable cancer with or without poor performance status (table).

    Details of the five sudden and unexpected deaths

    View this table:

    Sudden and unexpected death was not uncommon. Our data suggest that even in palliative care a definite decision could save instant decisions having to be made, reduce the risk of inappropriate attempts at CPR, and ensure CPR is not withheld when it is appropriate.


    Cite this as: BMJ 2009;338:b2343


    • Competing interests: None declared.


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