However, if a person is dying from organ failure, frailty or advanced cancer, for example, and his or her heart stops as a final part of the dying process, CPR will not prevent death and may in fact do harm.

A recent article in the BMJ¹ led by David Pitcher, immediate past president of Resuscitation Council (UK), describes how an emergency care and resuscitation plan might be formulated with the patient, family and healthcare team of realistic and individualised care preferences that might otherwise be done badly or not even attempted.

The aim of ‘do not attempt CPR’ (DNACPR) decisions is to protect people from receiving CPR that they do not want or which will not provide overall benefit. Making CPR decisions separately from decisions about other treatments has been challenging for clinicians and patients and has caused problems. Misunderstandings, poor communication and inconsistent DNACPR documentation persist, despite national guidance and protocols.

The authors offer suggestions on how clinicians and their patients might better think ahead, consider, discuss and record patient-centred recommendations, not only about CPR but also other elements of emergency care and treatment. 

In a linked article, Fritz et al² explain why a change in practice and culture, timing and context of these conversations is needed.

An emergency care plan allows clinicians to discuss and record the preferences of the patient in advance, not only about CPR, but about all aspects of their care and treatment in an emergency. An emergency care plan provides recommendations for care and treatment in the eventuality that the person does not have the capacity to communicate their preferences. The plan should be tailored to each patient, taking into consideration the most likely situations for the individual, such as a sudden acute illness, deterioration in a long-term condition, or sudden cardiac or respiratory arrest.

Current practice on DNACPR in Ireland emphasise that the decision is made by the patient where he or she is competent to do so, and otherwise by the doctor in consultation with concerned parties such as relatives, carers, nurses and other people close to the patient. All too often doctors abdicate this decision to patients’ relatives by asking questions like “do you want us to resuscitate your father/mother etc?

Patients’ relatives are not qualified to make resuscitation decisions for two reasons: firstly, because they lack the specific medical knowledge and training needed to make such a decision and, secondly, because they will be biased or prejudiced by their close personal relationship with the patient. 

Of course patients’ families must be consulted as part of the decision making process – it would be at best unwise and at worst unprofessional not to do so. But the final decision rests with the doctor who must bear both the authority and the responsibility for making it.

References

1. Emergency care and resuscitation plans. Pitcher D et al. BMJ 2017; 356:j876
2. Resuscitation policy should focus on the patient, not the decision. Fritz Z  et al. BMJ 2017; 356:j813