I've just posted this question a doctor sent to me on DiA Facebook - if this chap has arrested at home should the 999 paramedics attempt CPR ?

20/04/17 - 13:31
mike stone
I have just posted this question on the Dignity in Action Facebook page (about 3 hours ago), and as I've got some responses, I thought I'd try it here as well.

I sent an e-mail to a doctor who posts about cardiopulmonary resuscitation a few days ago, and yesterday he sent me a rushed but quite lengthy e-mail, and in it he asked me a question.

Would anyone like to contribute their own answers to this - if I get some, I'll pass them on. My own answer to this question [I'm not going to give it here - I do not wish to 'prejudice' any responses] is not the same as the guidance I keep reading.

Here is the question in the e-mail:

But I am going to ask you to consider a scenario. I am going to be quite binary, as you will have to make a quick judgement call pls! You are the ambulance man attending the following call: How would you manage it:

Scenario: Arrive at house after distress call. 72 yr old man, looks fit and well. Some cardiac history, takes tablets for arrhythmia, but not much other information. No pulse, not breathing, at present collapsed 18 minutes ago. No DNACPR form in house, but 3 family members firmly say "Don't give CPR".

Reply

Because I have no background information I should allow the 3 family members time to explain the situation but in the absence of a DNACPR form I'm concerned that I may lose my job if I don't act immediately so I will begin CPR. I'm not worried about the family members complaining at a later date because I was acting according to my training and judgment.
Difficult because the three people should be able to produce the DNACPR Certificate, however, they would not be expected to produce same if the collapsed person was in an other location such as a supermarket or in a bus queue....
I have decided that these replies are likely to be useful as a learning or teaching resource, so they need to be in one place and open-access.

Therefore I plan to post the responses from the Dignioty in Action Facebook page in this thread, as I periodically harvest them.

These are the responses on DiA to date:

Nick Dando 9:47 yesterday

I would give cpr. In an emergency situation you don't have time for the discussion required, better to attempt to save life-

Nick Dando 9:58 yesterday

I misread the post and didn't see he had collapsed 18 minutes ago. I suspect that would change my answer

Rachel Louise Scurr 9:51 yesterday

My heart says let the man rest in peace and I would be happy to do that although I suspect the guidance is different.x

Amanda Vickerman 10:21 yesterday

I wouldn't, it's the 18 minutes, although how do we know that is accurate

Jacquie Moss 23 hours

Cpr should be given, he is a relatively young man and I would not hesitate

Sharon Symonds 23 hours

Accept the family decision as his advocates based on how long he has been down

Sharon Coley 22 hours

Give cpr, until the gentleman concerned can state his own wishes then the lack of a DNR should be an assumption that he wants to live, in regards to the families wishes again I would have to make the assumption that they may not have his best interests in mind x

Alison Parish 22 hours

No don't give it. Someone decided it was his time to go and he left without too much suffering hopefully. To bring him back who knows what torturous illnesses could be around the corner for him.
I spk as one who cared for mum until her passing of a dreadful disease with lots of pain and suffering. The grief is terrible remembering what she had to go through. Would have much rather her had a pain free end

Liz Taylor 21 hours

My heart says that given the amount of time he's been down, assuming that's accurate, then don't give it. That is a much more dignified way forward. However in the absence of a DNAR the ambulance personnel have no choice, they have to give CPR. Just goes to show the importance of having this discussion and making your wishes known in writing at an early point.

Jane Finnerty 13 hours

I do agree Liz. Hard for a loving family but easier if they know your wishes

Valerie Kenyon 21 hours

In the absence of the correct form which the patient would completed with his expressed wishes I would have to attempt CPR and explain my position to family .

Mike Stone 21 hours

Can I ask - is Valerie Kenyon a HCP: paramedic, nurse ?

Valerie Kenyon 18 hours

Why?

Mike Stone Just now

Because I'm interested to understand whether what the effect of 'professional training' is on how people respond to the scenario: obviously laypeople will not have been influenced by training, but HCPs probably will have been. I'm a layman - but I've been influenced by my experience when mu mum died at home, and by my reading of the MCA.

Mike Stone 21 hours

And I forgot to say - thanks for the responses so far. A better response rate than I had expected. I've just sent the responses so far, to the doctor who put the question to me.

Dudley Cil 19 hours

As there no written instruction, try cpr there is nothing to be lost. It is the 1st principle of medical ethics to preserve life. Unless rigger mortis has set in.

Rochelle Monte 16 hours

I am delivering CPR training tomorrow and I would advise staff to call 999 and commence CPR. As no advance directive in place . And would suggest to family that they need to have formal agreement in place with the gentleman's consent should he survive.

Sally Hastings 1 hr

I'd go ahead with CPR he's only 72. His family may have information but without a legal document it's elementary.

Mike Stone 1 hr

All being well, on Monday I will post the answer I sent to the doctor, and also the response he sent to my answer. After a little time for people to ponder those, I will post my version of a conversation between the man and his GP.

I will throw in a question now. People are talking about 'DNACPRs' and 'documentation'.

The term 'DNACPR' usually means a written document signed by the senior clinician (GP here) but NOT by the patient. An Advance Decision refusing CPR would be signed by the patient and witnessed (the witness can be anyone, when I read the MCA) so a written ADRT forbidding CPR could be produced by those 3 relatives even if there was no 'DNACPR', and no mention of the ADRT in the wider records.

Would people (999 paramedics, etc) react differently if the relatives showed them a written ADRT forbidding CPR, which was signed and witnessed but did not seem to be 'embedded in the wider records system', compared to finding a DNACPR in the medical notes [a DNACPR not bearing the patient's signature - just the GP's signature] ?

I also posted this same question in the Dignity in Care discussion forum yesterday at:

http://www.dignityincare.org.uk/Disc.../Discussion_forum/...

Two replies so far:

Dal Morlar
Because I have no background information I should allow the 3 family members time to explain the situation but in the absence of a DNACPR form I'm concerned that I may lose my job if I don't act immediately so I will begin CPR. I'm not worried about the family members complaining at a later date because I was acting according to my training and judgment.

Suzie Lloyd
Difficult because the three people should be able to produce the DNACPR Certificate, however, they would not be expected to produce same if the collapsed person was in an other location such as a supermarket or in a bus queue....

Sharon Symonds 1 hr

I requested paramedics ceased cpr when attending my father at home on the day of his hospital discharge. I had no advanced directive available but they did not question my decision and stopped, explaining that they have to commence cpr when attending . I was grateful they were responsive to my request as couldn't imagine my father having to suffer any more than he had already
A work colleagues father was taken to hospital following cpr as he had a faint trace and then 'hung' on for a few days before dying again.

Mike Stone 48 minutes

The doctor who sent me the question, sent this back to me when I sent these DiA responses to him yesterday afternoon - I only opened this e-mail to me after my previous post (which answers one of his questions [about 'the son' - wait until Monday !] - and as you can tell, both of us are grateful for the contributions people are making:

Wow, thanks Mike. I'm sorry I have so little time with email and I have only been able to skim your previous ones. But the responses from your fellow DiA users are very enlightening. Some replicate the answers I receive at my teaching sessions.
Have you 'fed' them the next call yet? (from the angry son)

Sally Hastings 31 minutes

Gonna change my mind having reread Mikes original post. 18 mins is a long time. Thought it read 8 mins. My mistake! Would not give CPR

Sally AJ Boyle Thompson 15 minutes

This is very interesting. Especially reading everyone's responses.

Mike Stone Just now

'Responses' are usually more informative than either the question (but a good question, will lead to better responses) or the original article: the comments to British Medical Journal articles are very often 'a much better read' than the original article.

CURRENT TIME IS 10:44 on Friday 21 April



The Abul. Control should have the DNR order/ Tep registered on their data base by the GP if the GP has done their job correctly . This is also the same if the Hospital has carried out the completion of the order.the new orders are hospital/ community transferable that float with the patient.
In these situations there is never going to be a clean decision without a directive from the individual, medical staff are often damned if they do and damned if they dont now even more driven by litigation.
Families are often the least able people to make these decisions for many reasons some often distasteful, if a family member is close to the individual then they should have knowledge of what the person wants and has decided on making the appropriate wishes valid by documentation, we do not like talkind about what if this happens? but most people do at some time, it is time for the individual to be more pro active about what their wishes are should they experience critical illness, In the scenario presented one would imagine that the person was already clinically dead and surely when the family called 999 they would have been advised to administer CPR,
Hi Kevin,

I joined Twitter on Friday. Put a question to Dr Gordon Caldwell and got this answer to it:

Dr Gordon Caldwell? @doctorcaldwell 23h23 hours ago
More
Replying to @MikeStone_EoL
Best current advice would be Don't phone if you don't want someone to do #CPR Until some wisdom comes back for Care of the Dying


I can't find the tweet with the question I asked him - I think I asked him about my closing scenario in my piece at:

http://www.bmj.com/content/356/bmj.j876/rr-7

The 'question' is in the scenario:

To Close: (hypothetical)

I have been sharing a home with my now 'dying partner' for 20 years, although my partner has only been 'dying' for about six months. I have talked to my partner a lot during this six months, and during those 20 years. The GP has talked to my partner a little, especially recently. We both talk to the district nurses who have visited a couple of times a week for the last 6 weeks - but they are often different nurses each visit.

My partner has just collapsed. I have called 999 to find out why my partner has collapsed. I am now standing over a 999 paramedic, who is doing something to my unconscious partner. Why on earth, should I accept that this paramedic decides what happens next ?
Harvesting contemporaneously from DiA:

Mike Stone 3 hrs

I have decided to collect all of the replies to this question together in the Dignity in Care forum piece at:

http://www.dignityincare.org.uk/Disc.../Discussion_forum/...

Anybody can read the thread on DiC (you can only comment in DiC if you have joined, but anybody can view the discussions) and I know I will always be able to find the DiC discussion by using that web-link above: I still don't understand how you keep track of discussions on Facebook.

I do think this question from the doctor [which is very similar to questions I keep asking - don't get answers, but I keep asking] is a VERY IMPORTANT one.

I joined Twitter yesterday, at the suggestion of a doctor: I am not entirely sure how useful Twitter is for complex discussions (although I am 'already cheating' - effectively posing much longer initial questions than should fit within a 140-word tweet [hint: an image is not necessarily a photograph]).

My Twitter username is @MikeStone_EoL as I understand it (could be wrong)

I've also borrowed a book, to try and figure out how to use Twitter - 'borrowed a book' shows my age !


Sally Hastings 2 hrs

I've been on twitter since it's conception and only posted a few tweets. Not sure about the "trolling" side of it. So be prepared for a few challenges about your views.

Mike Stone Just now

Hi Sally - yes, my first thought was that Twitter will be deeply confusing for me (and it is) and full of 'shouty people'. However, I put a question to Dr Gordon Caldwell yesterday - I can't find my tweet to him, but I think I asked him about the scenario I put at the end of my piece at:

http://www.bmj.com/content/356/bmj.j876/rr-7

It is not exactly identical to the scenario the doctor sent to me, which is being discussed in this thread - but, there is truth in this tweet from Dr Caldwell

Dr Gordon Caldwell? @doctorcaldwell 23h23 hours ago
More
Replying to @MikeStone_EoL
Best current advice would be Don't phone if you don't want someone to do #CPR Until some wisdom comes back for Care of the Dying
Religious beliefs have to be considered like Jehovah Witnesses etc..I don't have DNACPR lying around at home.....where did the HUman Rights Act go now just because of someone nervous about their job? I also have rights, I also have beliefs, and if I don't want resuscitation and blood donations, that must be taken into consideration.
I have just added the answer I sent to the doctor, and also his reply to it, to the Dignity in Action Facebook thread - here it is

Mike Stone 26 minutes

This is the answer I sent to the doctor:

In your scenario, ignoring that the paramedic would currently be influenced by his protocols which say something different, then in my opinion what should happen is:

The paramedic asks these 3 family members 'are you telling me that you don't think I should attempt to resuscitate him - or are you telling me that you are convinced, from what he has said to you, that if he were able to, he would tell me to not attempt CPR ?'

If the latter, the paramedic should not attempt CPR in my view: if the former, the paramedic should attempt CPR, I think. Even if only one of the three says 'I know he would want CPR', CPR should be attempted. But - one of my issues - any family carer who is convinced that the person would have refused CPR, should not call 999 if the carer is aware that 999 would attempt CPR.

Professionals, seem to have decided that 'while a decision as respects any relevant issue is sought from the court' in 6(7) is somehow 'optional' in an 'emergency''.

I think that is dangerous for paramedics:

http://www.bmj.com/content/352/bmj.i26/rr-2


All for now, best wishes, Mike

PS 18 minutes with no circulation - which is possibly the case in your scenario - would probably lead a rational 72 yr-old to say 'I wouldn't want CPR attempted': if the person had thought about it. Which introduces issues around both 'rational' and 'thought about it' !


The doctor came back with:

Yes, I thought you might bring up the rationale for actually initially making the call in the first place. Truth is, many people panic and just don't know what to do, so they call 999 (even when DNACPR in house).

Often the best people to call if DNACPR is there already, is the GP surgery if in-hours or the out-of-hours service, although their response can vary too.

However, this was a scenario with no DNACPR. I ask my students to then reflect on the following scenario: an irate son who was not at the house phones up and tells the GP surgery that his father was in fact on the waiting list for an implantable defibrillator device; his cardiac arrhythmia was on occasion life-threatening, and so his father had wanted such a device to give him an emergency jolt if he went into Ventricular Fibrillation or pulseless VT. Defibrillation forms part of standard CPR, so why was his father denied this? How dare the paramedic listen to what auntie Mabel, auntie Dottie, and nephew Jamie had said at the scene?

I've exaggerated this a bit, but this is a scenario we often role out. It can be a career ending phone-call for a paramedic.

How would you deal with this son?
HI Mike

Just to add to the debate, I picked up from the Nursing Times that a nurse was given a 24month caution after failing to give CPR to a care home patient 'who was almost cold' when she arrived on the scene. I think this just adds to the debate in that there is a clear expectation that professionals will give CPR unless there is a clear written instruction otherwise. It is unclear to me whether this needs to be am advance directive and/or a DNACPR. My guess is that it will come down to case law, and in the meantime how many 'mistakes' and 'actions' will continue that result in people not receiving the dignified support and indeed death that they had hoped for.
We mustn't confuse residential and nursing home patients, (like the nurse who got the caution), with patients AT home. The English language differs here.
Almost all "homes" have a file on their residents stating what their best wishes and interests are, plus they usually state what their end of life decisions are.
People "at home" don't have files that contain data of this nature, but this doesn't mean their wishes and interests must be ignored. It might be in a will and last testament, a signed piece of paper, etc.
Hi Liz,

That NMC warning is something I asked about on Twitter yesterday - I wasn't aware of the case, and someone pointed at a subsequent statement which made sense, but I couldn't from that work out where the 'furore' was coming from.

Hi sally-Ann,

End-of-life patients who are in their own homes, will have 'files'. And you can create your own 'file' - you can decide to create a written ADRT forbidding CPR. The trouble is - currently discussing this on Twitter (a platform which I'm still struggling to get tog rips with - only joined last Friday, and I don't have a mobile phone) - that the 999 services typically ignore a written ADRT forbidding CPR [which carries legal authority] unless they can find a DNACPR form signed by a GP/doctor [and that does not carry genuine legal authority]. Remember that capacitous patients can make and change their decisions AT ANY TIME.

'Perverse' isn't the word for this - the NHS 'as a system' is not respectful of patient autonomy, and that has to change.
I might be losing track a bit, but I think the most recent replies from DiA not already moved over here are:

Maggie Blackmore 23 April at 18:10

18 "minutes is a long time but should not Medical ethics be followed up

Rochelle Monte yesterday at 10:17

I found this a good question to pose when delivering training, we wait in anticipation for the next installment


Nobody seems to have commented on my most recent addition yet - the 'irrate son' question posed by the doctor.

I hope people do comment - it is at that stage of the analysis (what the 999 paramedics do, and what happens next) when this discussion gets really interesting and informative.
Well we all know that the outcome wouldn't be good if indeed 18 mins had elapsed but we don't know that for sure so in the absence of a DNAR we should try
Hi Kirsty,

I will be posting - perhaps Thursday or Friday - a conversation the man and his GP had, when he decided to go on the waiting list for an implantable defibrillator device.
This situation has to be all about documentation ,had clients in past with none and ambulance crews and social services care managers unless provided with documents can not pursue situation.
A lesson for us all I think .
Hi Neil.

'A lesson for us all I think'

In my view more a case of:

'A conversation and debate about [mainly professional - it is 'understanding' that needs to be improved on the user side] behaviour, which we all need to have'
The question of if the paramedic should start CPR depends upon the indivividual Ambulance Trusts Resuscitation Policy. I do understand that people have their own views on what is "morally right" but when faced with making a split second decision registered professionals must follow the policies that are set. It is not that people are nervous about their jobs it is more that registered professionals are bound by their registration body to follow these policies.


I've just posted a tweet at https://twitter.com/MikeStone_EoL/status/857567980850479104
with a 'JPG' in it, that is actually a conversion from a PDF write-up of a survey I carried out a few years back. If you save the image and then open it at 1:1 viewing in an image-reader/editor, you should be able to read what I asked and what people answered (annoying, but I cannot attach PDFs either here or on Twitter - you used to be able to do it here, but no longer). The questions, and the answers, are relevant to the discussion we are having here.
It looks as if Twitter has shrunken my JPG and it isn't readable - annoying! I'm still finding my way around Twitter.
I have just had an incident where I had to run to a room and give CPR, but I could feel the skin was cold. Not only that, when the paramedics arrived, there was a single line on the monitor. THey honestly brought him back to life, by breaking his ribs, sawing into the leg for something, and they got a pulse. I steered the woman into the lounge, so that she didn't see all this.
They went to hospital, and he "died" 4 times on the way there. Another 4 times he was resuscitated. At the hospital, the doctor just walked up to the wife and asked what her wishes were, and she said, "let him die". That was it then, they allowed my resident to die peacefully. no more jerks and thumps on the body.
Why is it in CARE that the rules of engagement are so different? Why couldn't I have asked the wife exactly the same question?
THis man had choked on his vomit, had a heart attack, suffered a stroke a while back, and yet, I still had to perform CPR! His body had had enough, and only his wife could see this....................
Where was this guys dignity?

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