Analysis

When and how to discuss “do not resuscitate” decisions with patients

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2640 (Published 20 May 2015) Cite this as: BMJ 2015;350:h2640

When and how to discuss? Much earlier, and very differently!

Goldsmith and Gatland have written about a legal case with, as they say, important ramifications[1]. I was surprised, though, that they didn't mention the UFTOs (Universal Form of Treatment Options) referred to in the Tracey judgement as a good practice model for facilitating discussion [2].

I was also surprised that they didn’t include the part of the subsequent joint BMA / Resuscitation Council / RCN guidance which says that when CPR has “no realistic chance of success”, then involving people in the decision-making may mean “informing [them] of the [DNACPR] decision and explaining the basis for it”[3]. This raises important questions about when, and for which patients, there might be “no realistic chance of success”.

Surely, with the new consent law in the UK[4], ‘prudent patients’ need high quality information about the burdens and risks of CPR?

Unfortunately, quantitative questions on this topic are easier to ask than answer.

Routinely available data doesn’t differentiate between those patients who are dying because their heart has stopped; and those whose heart stops as a natural part of dying. We must, of course, try to resuscitate the former. CPR is less sensible for the latter.

We definitely need better evidence about which patients are, and are not, likely to achieve enduring ROSC (return of spontaneous circulation) after CPR. But is that enough?

Maybe we also need something more radical.

Maybe it’s about asking patients and families how they conceptualise ‘success’. Many people don’t only want to live longer. They have other priorities, too. And the most reliable way to know what someone wants is to ask. Ask early, and keep on asking, since priorities will inevitably change through the course of chronic conditions like heart failure and COPD. For cancer patients, we can start asking during treatment which aims to be curative. It might even help focus oncologists onto quality as well as quantity of life.

Shortly after the Tracey judgement, McCartney wrote about how CPR can medicalise inevitable deaths: changing last moments “from what could be a peaceful process into a medical battleground”[5]. We need to make sure that discussions about resuscitation are less damaging than CPR can be, and less traumatic than failed CPR attempts.

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[1] When and how to discuss “do not resuscitate” decisions with patients. BMJ: 2015;350:h2640

[2] See the very helpful discussion of this in: DNACPR decisions: challenging and changing practice in the wake of the Tracey judgment Clin Med December 1, 2014 vol. 14 no. 6 571-576 http://www.clinmed.rcpjournal.org/content/14/6/571.long

[3] https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/

[4] UK law on consent finally embraces the prudent patient standard. www.bmj.com/content/350/bmj.h2877

[5] Is discussing futile treatments really best for dying patients? http://www.bmj.com/content/348/bmj.g4180

Competing interests: Well before my own heart stops (which is hopefully not in the imminent future!), I would like support in thinking about and exploring my own priorities. Resuscitation will not always be my default 'choice'.

29 June 2015
Caroline Mawer
GP
London