LATEST guidelines from the RCN, BMA and Resuscitation Council pave the way for nurses to make clinical decisions on whether or not to attempt cardiopulmonary resuscitation.
Much of the document, published last week, provides guidance on changes in the law regarding Do Not Attempt Resuscitation decisions under the Mental Capacity Act 2005.
A key difference between this and 2001 guidance is nurses are now considered, in some cases, better placed than doctors to make such decisions – both in setting DNAR orders and in making decisions where there is no such order or circumstances mitigate against one.
Tracy Pilcher, chairperson of the British Association of Critical Care Nurses, welcomed the change, saying nurses were often closer to patients and best suited to take these decisions.
‘This is about making sure we are putting patients at the centre of decision-making. It is about the relationship that the nurse has with the patient. Nurses have often had the longer-term relationship – they have been caring for a longer period of time and understand patients’ perspectives,’ she told NT.
The guidance was covered widely by the media but its detail means it is not as black and white as suggested. It states: ‘The overall clinical responsibility for decisions about CPR, including DNAR decisions, rests with the most senior clinician in charge of the patient’s care as defined by local policy. This could be a consultant, GP or suitably experienced nurse.’
Therefore, the guidance is not a carte blanche for nurses to take control in CPR situations – its authors describe it as a basic framework around which local policy can be tailored.
The guidance also suggests only senior nurses should make the decisions but it fails to define the exact grade of such nurses.
Mike Hayward, RCN professional nurse adviser for acute and emergency care, envisages that only top nurse consultants with their own caseloads and who are independent nurse prescribers will be given the authority.
Mr Hayward said that RCN guidance on who would be able to make the decision is due to be published by the end of the year.
But how much of a real step-change does this represent?
The RCN claims many nurses are already making decisions and are simply referring to doctors for approval. ‘The old guidance was very restrictive,’ Mr Hayward said. ‘It put nurses in the position where they were having to ring GPs or
consultants to get a decision, when the GP or consultant has not seen the patient for some time.’
An NMC spokesperson said the regulator had received many calls from nurses on the issue, and, in theory, the guidance did not breach its code of conduct.
‘It is best practice that any individual nurse or midwife involved in a sensitive matter such as this ensures that decisions are not taken in isolation but have involved all members of the multiprofessional team and, where appropriate, the patient and family members,’ a statement from the NMC said.
‘There should always be an accurate and comprehensive record of any decision-making and discussion,’ it added.
The guidance points out that, as with other treatment, decisions to use CPR should be based on the ‘balance of burdens, risks and benefits to the patient’.