Should hospices be exempt from following national cardiopulmonary resuscitation guidelines? YesBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b965 (Published 27 March 2009) Cite this as: BMJ 2009;338:b965
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National guidelines already contain sensible advice regarding CPR decision making for the very ill. Presently, 20% our hospice inpatients are potentially for CPR. This, I hope, is a valid surrogate marker of non- discriminatory attitudes within our organisation. However, after 5,800 patients and 18 years of care, we are yet to encounter our first patient requiring CPR.
Less than one out-of-hospital cardiac arrest is likely every two years in a setting where 250 adults over the age of 50 spend 16 hours a day. (1) Increasing this statistic fivefold and applying it to our Day Hospice, which offers 48 six-hour places per week, we might expect one cardiac arrest every 22 years. An optimistic immediate CPR success rate of 5%, of whom 10% survive to return home, gives us one long-term survivor per 200 CPR attempts. We might witness such success once every 4,400 years if legitimate “not for resuscitation” decisions did not add thousands more years to that figure.
Such calculations do not weaken patient rights, but they do help to put the debate into perspective.
Reference 1. Hallstrom A, Omato J et al. Public access defibrillation and survival after out-of-hospital cardiac arrest. NEJM 2004;351:637-646.
Competing interests: None declared
CPR decision-making is an essential part of advance care planning for good end of life care and the revised joint statement and the recently released GMC guidance that is out for consultation are welcome strides forward in ensuring good practice in this crucial, complex and heavily misunderstood area of patient care across the UK. Hospices and indeed any specialist palliative care service should be welcoming such guidance and seeking to promote it rather than looking to be exempted and thus perpetuating the detrimental confusion that has previously existed. Making a distinction between the "process of dying" and a cardiopulmonary arrest is an unhelpful and retrograde step as this misunderstanding is the biggest hurdle in discussing the issue of DNAR with patients and their families. Death from a life limiting illness can be a gradual process but it can also be a sudden event. Just because a death is sudden does not automatically mean it was unexpected in the context of life-limiting illness. Equally there will increasingly be patients with life limiting illness (cancer and non-cancer) who require the expertise and environment of inpatient specialist palliative care for whom the absolute futility of a CPR attempt will be less clear cut. We cannot deny these patients the opportunity to sensitively but realistically explore their choices.
In NHS Lothian we have had a single integrated DNAR policy and documentation in use across all healthcare settings since May 2006 and the support of the Lothian specialist palliative care service, including the two hospices, has been fundamental to the policy's success. Our policy evolved from an awareness that patients, carers and staff were suffering as a result of the misunderstandings and confusions created by the existence of a vast number of different policies and DNAR communications across Lothian hospitals and hospices. We clarified the difference between a DNAR decison made because CPR would not work and therefore was not a treatment option (the position for most but crucially not all hospice inpatients)and a DNAR decision where CPR might realistically be successful in achieving medically sustainable life made on the basis of overall benefit in discussion with the competant patient. Our policy was and is absolutely in line with the revised joint statement from the BMA, RCN and RC(UK) 2007 and the new GMC good practice guidance and both hospices have implemented the policy and have embedded it into their general and specialist palliative care education without any detriment to the ethos of hospice care.
An additional benefit of our policy for patients is that the DNAR forms can, where appropriate, follow the patient home or to care homes and are recognised by the Scottish Ambulance Service and the police to avoid the unstoppable and distressing events that a sudden (but not unexpected) death at home can precipitate out of hours if the family panic and phone 999. This element of the policy only works if the patient and their family are aware of the DNAR form and so the issue must be discussed before the form can be left in the house and the decision registered with the out of hours service. As Watson et al points out many patients now are discharged from hospices - if a DNAR order has been appropriate for a patient in the hospice surely our ethical responsibility in this area of patient care does not end when the patient leaves the hospice ward? A recent audit at the Marie Curie Hospice Edinburgh by Dr Charlie Hall showed that we were able to have those discussions with 82% of patient being discharged home from the hospice. The potential burden of the discussion in this situation must be weighed with the overall benefit to the patient in knowing that a dignified and natural death is achievable at home even if their family should panic in the final moments and call 999 for help.
Rather than seeking to distance themselves from good practice guidance hospices should be leading the call for consistency and integration of DNAR policies and documentation in SHAs and Health Board areas. They should be confident in knowing how to apply the guidance for the ongoing benefit of the small percentage of patients with life-limiting illness who receive hospice care and should be fighting the ongoing battles of misunderstanding that the guidance documents are seeking to clarify. As Regnard and Randall emphasise a DNAR decision only needs to be made where cardiopulmonary arrest (death) can be anticipated and it only relates to the act of CPR. Any patient who deteriorates unexpectedly needs to be assessed and managed appropriately irrespective of a DNAR decision.
The bottom line is that the joint statement and the GMC guidance emphasise the individualised nature of these advance decisions and discussions where appropriate - surely if hospice care is about anything it is about truly individualised patient care.
Competing interests: Clinical lead for NHS Lothian integrated DNAR policy. Unpaid advisor to GMC End of Life care guidance.