Mike's Cheeky Blog: I believe that CPR should be attempted if a mentally-capable patient had asked for CPR to be attempted
I think - and the reasons are explained in the PDF - that 'the NHS' should change its 'rules around the attempting of cardiopulmonary resuscitation' and in essence remove consideration of 'could CPR be clinically successful?'. I consider that a different rule, which is in essence 'if a mentally-capable patient has asked for CPR to be attempted, then CPR should be attempted' would be more helpful.
Comments on this would be appreciated [after my PDF has been read, preferably].
Associated files and links:
Attempt CPR if you are asked to
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I think that the PDF you can download from my previous post, adequately 'argues the case'.
But, it is worth pointing out an example of how - despite the clinicians having been trying to 'deal with' CPR for years - they are still publishing 'guidance/policies' which can at best be described as 'logically incongruous', and more plainly as 'logically absurd'.
The 'consensus position' these days, seems to be 'to have two senior doctors writing that 'CPR would not work'' on documents.
Consider an ill or very frail patient, who is in a hospital. With plenty of time for hospital doctors to ponder 'if the patient's heart stopped beating, is there any realistic chance of re-starting the patient's heart?'. Setting aside the issue of 'in principle it should be absolute certainty - not 'very, very little chance'' at the moment, we seem to have hospitals creating documents on which two senior doctors write the equivalent of 'In our expert opinion, CPR could not be clinically-successful for this patient, so we ourselves would not be attempting CPR'.
Suppose the patient goes home, with no expectation that the patient's clinical condition could improve, and a couple of week's later the patient collapses, and 999 are called. The current guidance states that 'the attending paramedics have a clinical decision to make' if they arrive, and find the patient already in cardiopulmonary arrest. In this situation, the paramedics have almost no time to work with, and it is [a paramedic told me this] impossible for a 999 paramedic to work out 'why someone [whose 'death' doesn't appear obviously unnatural] arrested' by looking at the patient. While it seems plausible, that the paramedics might observe something which makes it LESS LIKELY that CPR could succeed, it seems really obvious that the paramedics CANNOT observe anything which make it MORE LIKELY that CPR could succeed: it is logically silly, to describe the statement by the expert hospital doctors that 'CPR couldn't succeed' as both 'an expert opinion', and to also suggest 'but during an emergency, and with the patient already in arrest when they arrive, paramedics can form a defensible clinical opinion that CPR would be more successful than the hospital doctors had suggested'.
A deeper analysis of what could be written on documents, and what the guidance for 999 staff could state, becomes very 'intricate' because it involves section 42 of the Mental Capacity Act, and the subsequent statement about section 42 in the Code of Practice: something I often sum-up as 'section 42 provides a 'weird pseudo-legal authority' by which senior clinicians can direct the actions of more junior clinicians - and it is clearly very problematic in practice!'.
My suggestion was being discussed on Twitter, with Ken Spearpoint, who is a CPR expert – Ken doesn’t support my suggestion. The discussion can be found in the PDF.
I ended my PDF with a comment, which I will show here:
And, I will make something clear: I almost agree with Ken – performing CPR on a
patient if you knew that the result would be ‘a lingering and painful or distressing
death’ is ‘abhorrent’.
There is obviously a reason why our heart, lungs, etc are protected by our ribcage – and CPR will often break ribs, puncture lungs, etc, even if it initially ‘restores life’. Many frail and ill patients in particular, who ‘are dying naturally and peacefully’, might be temporarily restored to life by CPR. But that life might include brain damage, mental capacity but serious pain, and many combinations but with an inevitable subsequent death in a matter of days. The damage caused by the ‘successful’ CPR, can lead to infections and other clinical complications, which the patient simply cannot survive, even with the best possible post-CPR medical and nursing care. That is horrendous – watching your peacefully-dying loved-one being restored to life by the quite brutal process of CPR, only to watch your loved-one suffering for a few days and then dying anyway.
I have also been reading the draft of something a charity is currently working on, and the e-mail I’ve recently opened after I had sent some comments on the draft ended with this sentence:
‘The primary objective is to get more people talking about later and end-of-life care. If we can do that, and avoid providing misleading or factually incorrect information, then we shall have done some good!’
That is ‘spot-on’ - and while I think the arguments I laid out in the first PDF in this thread make a logically-compelling case for the change I’m proposing, I honestly think the change would ‘get more people talking about later and end-of-life care’. I did NOT suggest that a patient could say out-of-the-blue ‘I want you to attempt CPR’ and that would not then lead to a discussion – if a patient said that to a doctor, and it wasn’t after a conversation around ‘we don’t believe CPR could work for you’, I would expect the doctor to explain what sometimes happens if CPR is ‘successful’: to explain that ‘lingering death’ I have described above. I suspect that then, many patients would say ‘I don’t want CPR then!’. Some patients would always want CPR. But at the moment, I’m told that understanding of the clinical consequences of CPR among patients and relatives is often very poor – I think if
the position was that capacitous patients would have CPR attempted if they asked for it, despite the clinicians thinking it would have a very bad clinical outcome, then there would necessarily be more discussion about CPR, and increasingly a better understanding within lay people of CPR.
After all – as Ken said ‘capacitous people being able to ‘demand’ medical treatment (CPR) that a body of evidence, knowledge & expertise know will not work when someone is dying is, I would argue, ethically abhorrent’ so surely doctors and nurses, would [at least try to] make clear the likely outcomes of CPR when attempted on patients who are very frail, or are ‘naturally dying’.
Associated files and links:
Twitter discussion about CPR
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On LinkedIn this morning, there was a post about a Doctor saved by a group of strangers giving CPR, nothing odd about that, except the Doctor had publicly stated that me could not see any benefit in teaching laymen CPR, apparently he has had a change of mind.