End of life and DNA CPR

Question 1

What rights does a patient have regarding CPR and who ultimately makes the decision to perform CPR?

Answer 1

Decisions regarding CPR are ultimately taken by the patient’s medical team
A patient can refuse CPR but not demand

Question 2

What is the outlook for those who receive CPR?

Answer 2

• Success of in-hospital resuscitation is ~20% but this may be much lower if there are comorbidities, i.e. depends on the health of the patient
• Of those who survive resuscitation, only around 50% will make it out of hospital

Question 3

In which circumstances can a DNAR form be complete?

Answer 3

1. Resuscitation is unlikely to be successful
2. The patient does not want it
3. It may be successful but would result in a length and quality of life that is not in the patient’s overall benefit

Question 4

When should and shouldn’t a patient be made aware of a DNACPR request?

Answer 4

Should:
- If a patient has capacity

Shouldn’t:

• Communication of decision will cause significant physical or psychological harm
• If a patient does not have capacity - relatives should be informed

Question 5

How do you approach discussing DNA CPR with a patient?

Answer 5

• Work your way up to it rather than diving straight in
• Build rapport and start by discussing current problems and how they’re being treated
• Explain there is always a risk that things might get worse and the patient might deteriorate
• Explain what CPR is and what it involves
• If CPR would not be successful, sensitively explain why your team feels it would not be appropriate
• If CPR might be successful, discuss the patient’s wishes and feelings
• Try to determine whether the benefits would outweigh the risks and burdens; and if the level of recovery would be acceptable to the patient
• Stress that a DNAR decision does not mean that the patient will not be treated - it is only relevant if their heart stops
• Do not ask the patient or relatives to make the decision
• If the patient/relatives strongly disagree, don’t force it - escalate the discussion to your seniors and ask for a second opinion

Question 6

What phrases can you use to sensitively discuss the topic?

Answer 6

• ‘One thing that it is important for us to talk about is resuscitation.’
• ‘You are very unwell at the moment and we need to talk about what we would do if you were to get worse despite treatment.’
• ‘We feel it would be kinder and more appropriate to ensure he is not in any pain or distress in the last moments of his life. If it were to get to the point where his heart stopped, we would not try to restart it.’
• ‘We will still give her every treatment available on the ward. The form just means that if she were to become much more unwell and reach the natural end of her life, we would not do chest compressions and shocks to restart it, because this can cause a lot of pain and distress, and prolong suffering.’
• ‘His medical condition means that he will eventually get to the natural end of his life and it is important we talk about this before it happens. Trying to restart his heart in this situation would not be the right thing to do.’
• ‘We only have one chance with end of life care so it is important to get it right.’
• ‘Even if a patient survives resuscitation, they are often more disabled afterwards, and left with a quality of life that is not acceptable to them.’

Question 7

Besides CPR, what other treatment escalation decisions need to be made when discussing EOL care?

Answer 7

• Invasive treatments
• Intensive care admission
• NIV
• Parenteral nutrition
• Again, the patient can only insist upon things that they do not want, and cannot demand treatment

Question 8

What factors need to be taken into account when considering intensive care admission?

Answer 8

• Diagnosis, severity of illness, and prognosis
• Age, comorbidities, and physiological reserve
• Anticipated quality of life
• Patient wishes