A framework for making advance decisions on resuscitation

Abstract

-Decisions about cardiopulmonary resuscitation (CPR) continue to cause difficulties for healthcare professionals. Current UK guidelines provide information on the underlying principles, but do not include a clear decision framework. The resulting confusion about when and who to ask about CPR can result in an inappropriate burden being placed on patients, partners or families. A simple clinical decision framework is presented, together with the underlying principles. This framework is offered as an aid for clinicians and patients in understanding the current ethical, clinical and legal guidance on decisions about CPR. KEY WORDS: algorithm, cardiopulmonary resuscitation, clinical decisions, hospice care, learning disability, palliative care, terminal careCardiopulmonary resuscitation (CPR) is a lifeprolonging treatment, and decisions about CPR should be made according to the same principles and process as other life-prolonging treatments. Two important factors affect decisions about CPR at the time of the cardiorespiratory arrest. The first is that there is little time available for any deliberation since, if CPR is to be successful, it is imperative that it is started immediately. The second is that a collapsed patient lacks the capacity to consent to or refuse CPR. The combination of these two factors has led to the development of policies designed to make the decision about CPR in advance of the event. These are often referred to as deciding 'resuscitation status' or making a 'Do Not Attempt to Resuscitate (DNAR)' decision. The idea behind such policies is to make a CPR treatment decision when there is time for deliberation about the benefit, harms and risks of CPR, and to ascertain in advance whether the patient would wish to consent to or refuse CPR. When the patient is involved, the resulting decision is an 'advance decision' , sometimes also referred to as an 'advance statement,' 'advance directive' or 'living will' .Unfortunately, the apparently simple idea of making advance decisions regarding CPR has proved extremely difficult to implement in practice. There are several reasons for this difficulty.• There is a reluctance to appreciate that, as with other life-prolonging treatments, the justification for attempting resuscitation rests on a reasonable balance of benefit to harms and risks.• There is an obvious difficulty in making a decision about CPR treatment in advance of any knowledge about the clinical circumstances in which the future cardiorespiratory arrest will arise. This leaves professionals unable to ascertain the balance of benefit to harms and risks of CPR when the arrest occurs.• There is confusion about the role of the patient, partner or relatives in the decision.• There is a lack of appreciation by both patients and professionals that an advance decision about CPR should be implemented under the same principles, and ethical and legal guidance, as any other advance statement. Case examples illustrating confusion in clinical practiceA These case studies are based on true situations...

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