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Views And Reviews Acute Perspective

David Oliver: Resuscitation orders and reality

BMJ 2016; 352 doi: (Published 15 March 2016) Cite this as: BMJ 2016;352:i1494

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It would be much simpler if techniques for CPR did not exist

The existence of CPR results in a plethora of 'issues'. I am not suggesting that 'the possibility of attempting CPR is bad' but:

Without CPR techniques, there could be no DNACPR decisions - so 'DNACPR' could not be conflated with 'expected death' as it often is (refs 1 & 2);

Currently if there are two patients with identical clinical conditions, but one is at home and the other is in hospital, the one who is at home is much more likely to be told 'that we [clinicians] do not intend to attempt CPR because we consider it could not be successful' than the patient who is in hospital - this rather unsatisfactory situation would not exist if there were no techniques for CPR;

Without CPR, 'alignment of mindsets' between relatives [who, I believe, tend to see 'my dad doesn't want you to attempt CPR' as the justification for DNACPR] and clinicians [who, it seems to me, are much more concerned with 'could CPR be successful'] would not be a problem for CPR decision-making. When I constructed a 'DNACPR Justification Hierarchy' (ref 3) I placed 'the patient is understood to have refused CPR' at the top, and 'successful CPR seems clinically very unlikely' much lower: but doctors seem to be more concerned with 'we predict that CPR would fail';

If CPR is discussed in advance [as it should be] there is an obvious possibility [even more so, if the discussion takes place when the patient lacks mental capacity] of 'very heated argument' ensuing;

If a person arrests at home, then irrespective of the cause of the arrest [or of the probability of an arrest occurring], there is a very real possibility that if CPR is attempted there would be 'resuscitation but with significant brain damage' [because of oxygen-starvation of the brain]. This makes a decision to 'absolutely refuse CPR if I am home when I arrest' entirely reasonable and rational (a person could prefer the certainty of death, to the uncertainty of the outcome of attempted CPR), and it seems to me 'perfectly legal' to make that refusal - but (see 'Alan and Liz' in ref 4) all I can say is 'good luck to anyone who tries to do that' !;

It is even possible, to describe a situation when it is obviously ethically correct to only attempt CPR if it were 100% certain that CPR would not restart the patient's heart (ref 5).

Another complication, is that a legal analysis of the situation when the patient/family want CPR to be attempted but the clinicians consider it would be clinically unsuccessful, is even more complicated than of the situation when a patient seems to be 'unwisely' refusing 'potentially-successful' CPR and clinicians 'are disturbed by' that refusal.

Mike Stone

Ref 1

Ref 2

Ref 3

Ref 4

Ref 5

Competing interests: No competing interests

18 March 2016
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN