1.0 Preamble PATIENT - CARDIO-PULMONARY RESUSCITATION POLICY 1.1 Cardiopulmonary resuscitation (CPR) is a medical intervention aimed at restarting circulation and breathing in a patient who has suddenly collapsed, that is, has had a sudden cardiac arrest. Basic CPR = mask ventilation and chest compression Advanced CPR = defibrillation, tracheal intubation and intravenous drugs used to restart normal cardiac rhythm. 1.2 Research has shown that CPR is largely unsuccessful in the majority of patients who suddenly collapse, contrary to popular belief. 1-3 Outside hospital and therefore away from advanced CPR facilities, the chances of success (defined as survival to discharge from hospital) range from 2-5% even with properly performed basic CPR. In hospital, the chances of success are greater, 15-20%, if the arrest is witnessed, occurs in a younger patient with a recent myocardial infarct and there are no other medical problems. 2 1.2.1 CPR in Patients CPR is regarded as futile, i.e., less than 1% chance of success, in patients with metastatic cancer (where the natural prognosis is regarded as months or less) who are bed or chair bound and who have co-existing medical problems such as heart or renal failure, pneumonia or hypotension. 4 It is important to differentiate a patient who is in a gradual terminal decline and dying from natural causes from a patient who has a specific and reversible cardiac insult. CPR for hospice patients will be futile for the majority. There is no ethical obligation to discuss futile treatments with patients and neither can patients or their relatives demand a treatment if it is considered futile by clinical staff. 5 For some patients those who are younger (<70 years old) with limited or early disease and whose physical functioning is good, it will be necessary to discuss this with them as CPR may not be medically futile. In potentially reversible causes of collapse (e.g. anaphylaxis to drugs or blood products) emergency drugs should be used and CPR should be attempted if cardiac arrest ensues. The patient s decision must be respected if it is made competently and any discussion should include: a) The chances of success being low, around 5% (1 in 20) and that advanced CPR facilities do not exist at St. Gemma s (no resuscitation drugs or defibrillators, no resident team of doctors out of hours). b) The quality of the death from their underlying disease compared to a sudden but painless cardiac arrest. c) The fact that surviving CPR will not result in a better quality of life or alter the previous prognosis, and may result in a reduced QOL that included disability or unconsciousness. d) Surviving CPR in the hospice will necessitate transfer by emergency ambulance to hospital ITU for further management. e) Reassurance that declining CPR does not result in being ineligible for other medical treatments thought appropriate e.g. antibiotics for chest infection, further radiotherapy, nephrostomy or stent insertion. Page 1 of 5
The decision on CPR for all patients should be recorded in the clinical notes. For the majority, the decision will be made by the clinical team and will result in not for CPR. For others, discussion with the patient will result in them opting for CPR or declining CPR if offered. Patient surveys have shown that the great majority of elderly patients expected discussion of CPR and were pleased to talk about this issue 6 but the number choosing CPR fell from 44% to 21% when they had been fully informed of the likely outcomes. 7 These figures are likely to be correspondingly lower in hospice patients. 1.2.2 CPR in visitors and staff Should a visitor or member of staff suffer a cardiac arrest then basic CPR should be started by trained staff and a 999 ambulance called. The nurse in charge should be informed and attend for support. Registered nurses on the other wards can also be contacted for support. 2.0 Policy 2.1. This policy applies to all doctors and registered nurses (=trained staff for the purposes of this policy). 2.2. This policy applies to inpatients, day hospice patients, as well as staff and volunteers who have a cardiac arrest at St Gemma s Hospice. 2.3. Doctors and registered nurses attend regular training in basic CPR. 2.4. The Health and Safety representative on each ward maintains basic CPR equipment. 2.5. Medical staff determine whether CPR would be futile for the patient based on knowledge of disease status, physical functioning or presence of valid advanced directive. 2.6. If insufficient information is available and the wishes of the patient are not known, a default position of FOR CPR will apply until further review. 2.7. All decisions regarding CPR are recorded in the clinical notes (on CPR status sheet) as soon as relevant information is known (see 2.5.) and reviewed at weekly intervals. 2.8. In situations where CPR is not futile or where doubt exists, this is discussed by medical staff with the patient explaining the points above. 3.0 Procedure In Event Of Cardiac Arrest 3.1. Doctor or registered nurse on duty undertakes basic CPR for patients who have sudden cardiac arrest and who have previously requested CPR after discussion with consultant/deputy or those who have a default position of FOR CPR. 3.2. Doctor or registered nurse on duty undertakes basic CPR for staff and visitors who have sudden cardiac arrest. 3.3. Co-ordinator ensures ward doctor (or on-call deputy) and nurse in charge are contacted. 3.4. Nurse in charge or deputy calls 999 ambulance and patient is taken to St James s hospital unless confirmed dead by doctor in attendance. 3.5. Nurse in charge or deputy calls 999 and staff / visitor is taken to St James s Hospital. Page 2 of 5
References 1. European Journal of Anaesthesiology 1998:15;702-9 2. Resuscitation 1996:32;169-76 3. JAMA 1995;274:1922-5 4. Dautzenberg PL, Broekman TC, Hooyer C et al. Patient related predictors of cardiopulmonary resuscitation of hospitalised patients. Age and Ageing 1993:22;464-475. 5. National Council for Hospice and Specialist Palliative Care Services. Ethical decision making in palliative care. London 1997. 6. Morgan R, King D, Prajapati C et al. Views of elderly patients and relatives on CPR. BMJ 1994:308;1677-8. 7. Murphy DJ, Burrows D, Santilli S et al. The influence of probability of survival on patients preferences for CPR. N Eng J Med 1994:330;545-9. Original Validation Date: August 2001 Revalidation Date: February 2007 Review Date: February 2010 Responsibility of: Consultant Page 3 of 5
CPR STATUS Document for insertion in patients notes 1. Would CPR be futile for this patient? YES NO Tick relevant reasons if YES: (a) (b) (c) Advanced, progressive disease where management is not aimed at prolonging survival Bed or chair bound Complicating medical illness (renal failure, pneumonia) 2. Is CPR contra-indicated for this patient? YES NO Tick relevant reasons if YES: (a) (b) (c) Presence of valid advanced directive Voluntary, verbally expressed refusal of consent Refusal of consent after discussion with medical staff 3. Has patient opted for CPR after discussion with medical staff? YES NO 4. CPR status FOR CPR YES NO Consultant (or deputy) signature...date... 5. Revised CPR Status FOR CPR YES NO Consultant (or deputy) signature...date... Page 4 of 5
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