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We need to talk about resuscitation

BMJ 2017; 356 doi: (Published 09 March 2017) Cite this as: BMJ 2017;356:j1216

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BBC Radio 4's 'Today' is doing its bit to get CPR discussed - can more of us join the conversation, please !

BBC Radio 4's 'Today' is doing its bit to promote the conversation about CPR. Yesterday (Friday 10th) it had Zoe Fritz as a guest, promoting 'ReSPECT' (I dislike ReSPECT – see ref 1). Today, Saturday, 'Today' had Beverly Tempest (I hope I have spelt her name correctly – I've tried to find her online to check, but failed) telling listeners why she has a 'DNACPR' tattoo on her chest, and Vivienne Nathanson explaining some of the complications around CPR.

Beverly, after her father's death following 'delayed CPR', wants to forbid attempted CPR if she arrests at home, because she is worried about possible damage from anoxia. She asked her GP 'how do I do this' and was told 'you can't do it because you are not terminally ill or near death'. Another doctor subsequently told her she would need to tattoo DNACPR on her body. Vivienne Nathanson said that 'what matters most is the discussion in the family, so that whoever happens to be with the patient can answer the question 'does the patient have any views about this ?'.

Beverly is a real-life version of the Alan in my 'Alan and Liz' scenario. See ref 2 and a link within it, for details of Alan – in brief, extracted from ref 2:

'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' !'

The problem, fundamentally, is twofold. The 999 Services – perhaps in contrast to senior hospital doctors – do not default to 'trusting the word of relatives, about the understanding the relatives possess in respect of the arrested-patient's position on CPR'. And secondly, the issue of 'where the risk of following a written Advance Decision forbidding CPR rests': surely, it should rest with the person who decided to create that written ADRT. I have discussed this in a PDF that can be downloaded from ref 3, where I reversed the assumption that 999 paramedics currently make about whether an ADRT forbidding CPR, which is not embedded in the medical records, should be followed if it is prima facie valid [and applicable]. When you 'think from the position of the patient who created an ADRT', you (well - I do) arrive at this:

One place where this can easily be seen, is the issue of cardiopulmonary resuscitation (CPR) when a patient is at home, and a cardiopulmonary arrest (CPA) is not considered likely. Clinicians often imply, in their writing, that in this situation the patient cannot refuse CPR by means of a written Advance Decision (ADRT). This is utter rubbish, logically: I am not expecting that a drunken driver will swerve his car onto the pavement and hit me, but I can certainly think about the likely consequences, if that were to happen. Similarly, I can consider the consequences of an unexpected CPA.

The only thing which does definitely follow from a home CPA being unexpected, is that the GP could not certify the death – but that is an unrelated issue, to whether I can use an ADRT to forbid attempted CPR for a ‘sudden CPA’.

If I consider such a ‘sudden CPA’ and then I write an ADRT refusing CPR for it, I would be doing that in the knowledge that if I were in CPA when 999 paramedics arrived at my home [after, probably, having been called by another person such as a spouse, who had seen me collapse], I would not be conscious – so, I would have written the ADRT with the intention that it should be followed, in exactly that situation (of an unexpected arrest, and when there was no time to look at my ADRT beyond confirming its Prima Facie validity).

Clinicians seem to think, that in this situation – when there is ‘an emergency’ – my ADRT can be ignored, because there is no time ‘to confirm it’. But to the author of such an ADRT, surely that is exactly the opposite of what you would expect – as I wrote in ‘ReSPECT is incredibly DISRESPECTFUL’:

‘An ADRT which appears prima facie valid should be accepted as being valid, if there is not enough time to check in more depth: it is during a non-emergency that the prima facie apparent validity of a written ADRT should be further examined !’

Ref 1

Ref 2

Ref 3

Competing interests: No competing interests

11 March 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN