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New guidance says CPR conversations must be 'sensitive but realistic'

  • 26 Comments

New guidance on cardiopulmonary resuscitation makes it clear clinicians should talk to frail patients about whether to attempt it at the earliest opportunity, despite recent concerns these conversations were not being handled sensitively.

The updated CPR guidance, issued by the British Medical Association, Resuscitation Council and the Royal College of Nursing, emphasises the value of making decisions about whether to attempt CPR in advance of a crisis where possible.

But it stresses these conversations should be undertaken by “healthcare professionals with the necessary training and expertise”, and carried out in a “sensitive but realistic manner”.

“For many people with advanced or multiple medical conditions the optimal time to undertake advance care planning is when they are relatively stable, in their home or usual care environment, where it can be supported by the healthcare professionals who know them well,” the guidance states.

“These may include doctors and nurses based in general practice, in the community, in hospices and in hospitals,” it adds.

“In working together to improve this guidance, doctors and nurses are helping ensure these difficult situations are managed in a way which does not add to the distress and confusion of patients and their loved ones”

Peter Carter

The guidance comes amid media reports that some sick and older patients were being left upset and confused, having been unexpectedly quizzed on end of life wishes by unfamiliar professionals, including district nurses.

Patients have also complained about getting phone calls out of the blue from practice nurses asking about resuscitation.

The guidance said discussing or explaining CPR decisions early on helped ensure patients’ wishes were respected and reduced the risk of them having treatment they did not want.

It also acknowledged that these conversations could be “difficult” for healthcare professionals, especially when it came to informing patients and relatives about do not resuscitate orders.

But it made it clear that where CPR had no realistic chance of success then a do not resuscitate order was entirely valid.

“Situations that involve attempts to resuscitate patients are among the most difficult for all concerned,” said RCN chief executive and general secretary Peter Carter.

“What this new edition of the guidance makes clear is that with good, sensitive communication from staff, individuals can plan, make their wishes known and understand the consequences of decisions around resuscitation,” he said.

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Peter Carter

“In working together to improve this guidance, doctors and nurses are helping ensure these difficult situations are managed in a way which does not add to the distress and confusion of patients and their loved ones,” he added.

The guidance makes it clear that ultimate responsibility for a CPR decision rests with the most senior healthcare professional caring for a patient, which could be a consultant, GP or senior or specialist nurse.

However, it also said there may be situations where another member of the team is best-placed to discuss these issues with the patient or their loved ones, such as a nurse involved in their day-to-day care.

The revised guidance also stressed the need for effective communication of decisions to other healthcare professionals in primary and secondary care, including ambulance clinicians and staff at residential and care homes, and careful documentation.

“The senior nurse is responsible for ensuring that every CPR decision is recorded in the nursing records (where the institution has separate nursing records), that those records are updated should the decision change and that all those nursing the patient are aware of the current decision,” said the document.

  • 26 Comments

Readers' comments (26)

  • michael stone

    I've sent some preliminary comments on the guidance to the BMA and RC(UK) {typically, the RCN doesn't give an e-mail address}, based on a partical reading of the new CPR Guidance. I'll be sending a longer comment, once I've worked through all of it.

    But the LACDPs 'One Chance to Get It Right' 'advice' seeks to promote those 'difficult conversations', and the new CPR guidance does the same. Although a lack of clarity about 'how optional' the discussions are (and the new CPR guidance is clearly written in light of the Tracey court ruling, at least in places) remains, and there is also a problem around 'patient confidentiality', which I've discussed at:

    http://www.bmj.com/content/348/bmj.g4094/rr/703333

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  • michael stone | 9-Oct-2014 2:49 pm

    so are you going to tell us how it should be done Michael?

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  • Anonymous | 9-Oct-2014 5:17 pm

    I think you have misunderstood what Michael Stone wrote. He has sent comments about the guidance, not written it.

    I welcome some guidance and training, as my friend's mother's GP rang her up the other week to ask her if she wanted CPR? She is at home, suffers from COPD, but not at deaths door. She was so upset and frightened, it has taken my friend great efforts and time to reassure her Mum she is not going to die imminently. That GP was extremely insensitive.

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  • Anonymous | 9-Oct-2014 9:46 pm

    my comment was address to MS and he understands perfectly well.

    As far as this guidance is concerned I do not agree with this NHS supermarket off the shelf healthcare and one size fits all. an experienced clinician will evaluate the individual needs of each and every patient and treat them appropriately and in the manner in which they wish to be treated. 'Know thyself' and Know thy patients!

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  • Anonymous | 9-Oct-2014 9:55 pm

    I don't agree with this one size fits all either, but all these guidelines seem to give no flexibility for GPs and others to provide individualised care, despite some (politically speaking) saying otherwise. That is because it is all connected with targets, which are connected to 'income' - a vicious circle (it has become). It is hard to believe that such an enormous workforce of highly intelligent and trained people have allowed this to happen. We've sat back and accepted everything that has been thrown at us.
    Personally, I have a problem with hyperlipidaemia. The 'last resort' statin, would probably 'suit me best', I was told. However, I couldn't have it because if it didn't control my condition, they would have no other statin option. So I am having to go through the chain of trying one after another. Having said all that, as the jury is still pretty much out on statins, I have opted out, for now, at least. As it is a NICE guideline, I suppose I am being labelled as 'not following the recommended treatment, a deviant in denial, or whatever'. I think insurance companies must be loving this.
    Unless, all medical professions unite and fight this so called 'big brother' notion, I fear it is too late to change.

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  • michael stone

    Anonymous | 9-Oct-2014 5:17 pm

    No, I'm telling the authors where their guidance is not unambiguously in line with the law, as it happens.

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  • michael stone

    Anonymous | 9-Oct-2014 9:46 pm

    There is a huge problem, with finding out whether or not a patient would want CPR.

    As you point out, lots of patients get very upset, if they are asked: on the other hand, lots of relatives who know their loved-one wouldn't want CPR, get very upset if CPR is attempted because 'nobody clinical asked'.

    There is, I think, a very general issue with this - as I wrote on BMJ, it seems to me that HCPs will talk about 'being very ill', and will discuss bereavement, but are very reluctant to discuss 'the death itself' with patients/relatives:

    http://www.bmj.com/content/347/bmj.f4085/rr/652862

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  • michael stone | 10-Oct-2014 10:36 am

    ah, so now we are claiming to be a legal expert as well as one on medical and nursing affairs.
    well done Michael! you tell 'em.

    where else do you talents lie?

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  • A large problem currently lies in the wholesale selling of DNAR's to older people. It is very clearly discriminatory by its nature, this is not happening for younger people with LD or MH issues. The use of DNAR for people who lack capacity and been made by GP's do in fact breach the MCA(2005) in that they are being made way in advance of any decision, it has to be time and decision specific. I had a client who called the ambulance for a lady complaining of chest pain, the ambulance staff saw the DNAR and said "is it worth taking her", now tell me there is not malpractice in the issue of DNAR's on a target basis to residents in care homes and within their own homes. This is purely to prevent older people having access to A & E.

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  • Anonymous | 10-Oct-2014 6:10 pm

    despicable and odious. this is what happens in the general management target orientated, greedy and selfish society britain has become where care is no longer focused on the needs of the individual.

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