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Analysis

Resuscitation policy should focus on the patient, not the decision

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j813 (Published 28 February 2017) Cite this as: BMJ 2017;356:j813

Re: Resuscitation policy should focus on the patient, not the decision

We welcome Zoe Fritz and colleagues new approaches to resuscitation decisions and the development of ReSPECT.
Fundamental to discussions about the benefits and burdens of emergency treatments, including CPR, is that the conversation is informed.
Therefore we were surprised with the statement ‘one in five CPR attempts made in hospital result in survival’, since this is not a true reflection of the frail, often elderly, population whom ReSPECT will benefit. In fact the statement references a study which examined the success of CPR in American Intensive Care Units, and only 15% of the study population were from non-monitored hospital beds. This latter group had a much worse survival (risk ratio 0.58) in comparison to the ICU patients.
In out Trust survival following CPR, outside a monitored area (critical care, coronary care, Accident and Emergency), varies between 0-4%, and so the informed conversation to our elderly, frail, population reflects this.
If ReSPECT is going to focus on ‘choices of treatments’, and ‘record patient preferences’ then the information given must be valid. It is likely that both the patient and doctor will opt for CPR in hospital if they are given a one in five survival chance. However if sympathetically explained that  if your heart stops during the dying process then CPR in hospital has at best a 1 in 25 survival chance and is likely to be associated with pain and distress, then the vast majority of our patients opt not for CPR.
ReSPECT has drawn on evidence of good practice from around the UK to structure its development. However even where practice is good (eg TEPs across Devon) uptake remains low and so fundamental to the success of ReSPECT is to encourage politicians, doctors, patients and the public to have the dialogue nationally and individually about dying (when the heart will stop), and the distress often caused by NHS investigations and treatments during the dying process.’
 
Finally let us be clear that in cardiac arrest the heart stops first, and early commencement of CPR may result in restoration of cardiac rhythm and cardiac output before serious damage occurs to the brain, kidneys and other vital organs. In ordinary dying the vital organs, including heart muscle, progressively fail until the heart stops beating and an agonal trace may be seen on the ECG monitor. Under this circumstance cardiopulmonary resuscitation (CPR) cannot work. Even if a heart rhythm and a weak cardiac output could be restored all the vital organs are terminally damaged.
The indication for CPR is cardiac arrest, and an absolute contraindication is inevitable dying from “all systems down”. In no other area of medical practice would the GMC condone using a harmful invasive undignified procedure for the wrong indication and in the presence of absolute contraindications.’
 

Competing interests: No competing interests

23 March 2017
Richard M Venn
Consultant in Anaesthesia & Intensive Care
Dr Gordon Caldwell, Consultant Phsyician, Worthing Hospital
Worthing Hospital, UK