David Oliver: Why I’m changing my mind about resuscitationBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1143 (Published 07 March 2017) Cite this as: BMJ 2017;356:j1143
All rapid responses
I am pleased that Professor Oliver seems to be moving into alignment with my own long-standing views about CPR. But, I do wonder why he wrote ‘I’m coming gradually to a view that, for hospital inpatients and care home residents, we should do all we can to avoid CPR without patient consent or best interest discussions with families’ and omitted terminally-diagnosed patients who are in their own homes: was that omission deliberate ? And if it was deliberate, is because Professor Oliver accepts that it is much more complex when patients are at home, but unlike me he wants to ‘work outwards from hospitals and care homes’ towards the complexity of arrest in a patient’s own home ? My position is that we should sort out the complexity of CPR within a patient’s own home first, when the people present and supporting the patient are 'family carers' instead of HCPs, and then extract from that necessarily sophisticated understanding the simpler ‘rules’ for CPR in hospitals, hospices and care homes.
Whatever reference 10 argues and concludes, I disagree about:
‘For registered practitioners, common law precedent already protects us in acting without patient consent in life threatening situations when time won’t allow otherwise.10 But, for most patients entering hospital, the possibility of resuscitation could reasonably be anticipated and planned for.’
My argument, is that if the probability of a CPA occurring is not insignificant, or if a patient has indicated a refusal of CPR however unlikely a CPA is, there should be an expectation that ‘contingency planning’ by the NHS must occur. I write about the MCA’s best-interests requirement, and anyone who has considered section 4(6) of the MCA must be aware of its complexity: that complexity clearly cannot be properly addressed during a CPA, without a lot of advance-consideration of ‘what should happen if a CPA occurs ?’. This effectively means that ‘the defence of necessity’ should fail, for anyone who is involved in an ongoing way with a terminally-diagnosed patient, or with a long-stay inpatient who might be at risk of a CPA. The logic, means that neither the GP of a terminally-diagnosed patient who is being cared for at home, nor the patient’s family carers, nor any regularly-attending district nurses, should normally be ‘appealing to necessity’ to justify attempted CPR: those people have a duty to plan ahead, because their decision-making if a CPA occurs, should be based on an attempt to satisfy the MCA’s best-interests requirement. The concept of 'necessity' is justified by 'ignorance' - if there was an opportunity to instead properly prepare for and then to make a CPR decision which complies with the MCA, and an appeal to 'necessity' is still resorted to, that looks rather unsatisfactory at best, and rather like' culpable negligence' at worst.
I canvassed opinion a few years ago, after someone (I think Iona Heath) floated the idea that the default should be to not attempt CPR ‘for the frail elderly’ (such patients would need to 'opt-in' for CPR). The question I asked, and the responses I received, can be downloaded at reference 1. That approach is also unsatisfactory – the only satisfactory resolution, is to ‘have held the necessary ‘consent discussions’’ in advance of the cardiopulmonary arrest.
Competing interests: No competing interests