A local newspaper recently published an article where it was reported that a nurse had been reprimanded for “not trying to revive a ‘dead’ woman” (Blackpool Gazette, 1st March 2017) and more recently in this journal.
The case attracted considerable interest on social media, with many healthcare professionals commenting in disbelief that the nurse had been cautioned by the NMC for what appeared to be a common-sense decision to withhold cardiopulmonary resuscitation. Others were left bewildered and confused by the outcome of the misconduct hearing held by the NMC, which drew many to conclude that they may find themselves in a similar, very challenging and professionally compromised situation.
The notes from the hearing indicated that the nurse, who was in charge of the care home at the time, had been called by a care assistant to see an 85-year-old resident who had been found unresponsive. The nurse then proceeded to assess the resident and noted that the woman was not breathing, had no signs of life, pulseless and was “waxy, yellow and almost cold”. The resident, whilst elderly, was not expected to die and did not have a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) order in place.
The case against the nurse, of misconduct and impaired fitness to practice wrested on two key issues ‘failing to commence CPR’ and ‘failing to contact or ensure that the emergency services were contacted’. There is much to contemplate in the complexity of this case, and we are not in full possession of the facts, but many could forgive an experienced nurse for making a seemingly appropriate clinical judgement of not commencing CPR and/or calling the ambulance service when faced with a patient she identified as being dead when the guidelines (BMA, RCN, RCUK, 2014) contain much that would appear to support such a decision as being in the ‘best interests’ of the patient.
Authors of the guidelines anticipated that such situations could arise and deliberately constructed the guidelines, using carefully chosen language. Referring to circumstances where patients are discovered with signs of irreversible death, section 8, paragraph 3 of the guidelines (BMA, RCN, RCUK, 2014) contained the sentence;
“In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies’.
In the interests of safer care, systems should be in place to protect both patients and nurses. In addition to existing vicarious liability arrangements, patients and staff should be ably supported by robust, well-written policies that guide clinical decision-making when finding patients apparently dead, in the absence of a DNACPR order. Policies should take account of professional judgement in line with national guidance and include information that identifies the consequences of failing to adhere to policy.
Furthermore, consideration should also be given to the conduct of timely, sensitive, meaningful discussion with patients and their family and/or friends to explore their thoughts about end-of-life advanced care planning.
As is evident, failure to do this could leave patients vulnerable to inadequate care and nursing staff vulnerable to legal, professional and ethical compromise.
Ken Spearpoint, Principal Lecturer and Emeritus Consultant Nurse, University of Hertfordshire