Decisions about cardiopulmonary resuscitation should be based on open communication between health professionals, the patient, and people close to the patient, taking note of patients' informed decisions and reflecting their best interests, recommends new guidance published for the United Kingdom this week.
The guidance, Decisions Relating to Cardiopulmonary Resuscitation, is a joint statement from the BMA, the Resuscitation Council (UK), and the Royal College of Nursing, setting out legal and ethical standards for planning patient care and decision making in relation to resuscitation.
It acknowledges recent public concern about “do not resuscitate” (DNR) orders after several cases in which patients or their relatives have complained that resuscitation orders have been written in notes without their knowledge or consent. The report also recommends a change to using the term “do not attempt resuscitation” (DNAR), to highlight the fact that cardiopulmonary resuscitation is a difficult procedure that is frequently unsuccessful.
The new guidance recommends that decisions about whether to attempt resuscitation should be reached in a way that follows an individual patient's informed decision—either made at the time or in an advance directive—or reflects his or her best interests.
Health professionals should make all reasonable efforts to attempt to revive a patient if their wishes about resuscitation are unknown or cannot be ascertained. Informed decisions—including those set out in advance directives—made by mentally competent patients that continued treatment aimed at prolonging life would be inappropriate should be respected.
The views of children and young people must be taken into consideration in decisions about attempting resuscitation. When they lack competence, children's parents should generally make decisions on their behalf.
The report reminds healthcare professionals that cardiopulmonary resuscitation should be used appropriately, following the primary goal of any medical treatment—where it maximises benefit and minimises potential harm to patients. Resuscitation decisions must be based on the individual patient's circumstances and reviewed regularly.
The guidance recommends that resuscitation should not be attempted in all cases of cardiac or respiratory failure but should be considered only where it represents an appropriate part of a patient's management.
In patients in whom cardiopulmonary arrest clearly represents a terminal event in their illness, attempted resuscitation might be considered inappropriate. Neither patients nor their relatives can demand treatment that the healthcare team judges to be inappropriate, but all efforts should be made to accommodate wishes and preferences.
All establishments where staff face decisions about attempting cardiopulmonary resuscitation—including hospitals, general practices, residential care homes, and ambulance services—are required to have policies to guide decision making about resuscitation.
Written information about resuscitation policies should be included in the general literature that is provided to patients about healthcare establishments, including hospitals and general practices.
The report explained: “The purpose is to demystify the process by which decisions are made. Information should reassure patients of their part in decision making.”
Decisions Relating to Cardiopulmonary Resuscitation can be seen on the BMA's website (www.bma.org.uk).