The Policy in Wales now seems to be to offer CPR to patients who request it even if the clinicians believe CPR could not work - and I approve of that.

mike stone 03/03/22 Dignity Champions forum

I have written some comments on the ‘new’ DNACPR Policy in Wales.

The policy can be found at:

https://collaborative.nhs.wales/implementation-groups/end-of-life-care/dnacpr/

As ‘backup’, I will attach the policy to the next post in this thread.

I draw the attention of readers to section 8.3 of this policy – I approve, and I have seen nothing akin to this in any other CPR policy which I have read (I must add, that during the Covid pandemic, I have not had enough internet-access to find and read CPR/DNACPR policies), and section 8.3 starts with:

8.3 A clear request for CPR – when CPR is not likely to be successful or clinically
indicated

A patient might insist that future CPR is provided - even when (for clear clinical reasons) the clinical team feel it to be an intervention which cannot provide clinical benefit and will not be successful. When a patient requests CPR following a discussion that clearly outlines very significant risks and burdens, the senior clinician must record fully the patient’s expressed wishes, alongside their own clinical views. When conflict exists and whilst further advice is sought, the interim position should normally be to call the emergency services or arrest team in an arrest situation, to consider CPR under current circumstances on arrival, as appropriate. Efforts should quickly be made to reconcile the position if at all possible. In some cases a multi-professional team review might resolve to follow the patient’s wishes in an individual case, and to provide CPR, even if it is felt that it will not work or even potentially cause harm. In other situations, however, the conclusion might be that attempting CPR in the circumstances would be clearly contrary to best clinical judgement and good practice. In such cases, a second opinion must always be offered and legal advice may become necessary with further discussion with the patient. When there is serious challenge to a DNACPR position, from whatever quarter, the legal and ethical position must be considered. Healthcare professionals, who take a fully-considered ethical and clinical position, should immediately share and document their concerns and receive support from their organisation.

The sentence I approve of, and which seems to depart from previous policies on CPR, is:

In some cases a multi-professional team review might resolve to follow the patient’s wishes in an individual case, and to provide CPR, even if it is felt that it will not work or even potentially cause harm.

This is something I have argued for on Dignity in Care, in my 2019 piece at

https://www.dignityincare.org.uk/Discuss-and-debate/Dignity-Champions-forum/Mikes-Cheeky-Blog-I-believe-that-CPR-should-be-attempted-if-a-mentally-capable-patient-had-asked-for-CPR-to-be-attempted/1051/

Associated files and links:

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mike stone 03/03/22

I have attached the policy I commented on (just in case it is revised, and can then no longer be found - sometimes only the most recent version of something can be found online, and my comments in the previous post are on this [attached here] policy).

mike stone 03/03/22

Does anyone know of a CPR/DNACPR policy in England, that explicitly supports [requested] attempted CPR even if the clinicians believe that CPR could not work?

Mark Taubert told me on Twitter this morning that it has been in the policy for several years (I think he said since 2015) - I had not been aware of that (and I'm not sure why I wasn't aware of that - I think I'd read an earlier version of the Wales policy). But when I asked Mark if he could point me to some policies in England that say the same thing, Mark said '... should have been clearer - I meant for some years in Wales'.

I live in England - does anyone know of a policy in England, which has the same position as Wales?

mike stone 08/03/22

NOTE: when I am quoting from the Policy, if you see ‘…’ in the text, it means I have missed out a section of text – not to try and ‘hide something’ but to make my argument simpler to follow.

I have managed to get a little bit of discussion on Twitter: as Twitter is ‘somewhat fragmented’, I’ll post something coherent here and point to it from Twitter. The sentence which seems ‘striking/new’, and is disliked by some (or perhaps most - I'm not sure) clinicians, is in the Audit point of section 8.3:

‘It should be considered an “exceptional clinical event” to pursue a DNACPR position that is contrary to the expressed views of the patient.’

Within the text of section 8.3, there are two consecutive sentences which invite some thinking:

‘In some cases a multi-professional team review might resolve to follow the patient’s wishes in an individual case, and to provide CPR, even if it is felt that it will not work or even potentially cause harm. In other situations, however, the conclusion might be that attempting CPR in the circumstances would be clearly contrary to best clinical judgement and good practice.’

The ‘thinking’, is that NHS clinicians are not usually expected ‘to make decisions on a whim’: normally there should be some sort of ‘reasoning or process’, which can be looked at ‘from the outside’, beneath a decision made by a doctor or nurse. It isn’t at all clear, how an MDT’s decision about CPR can be ‘interrogated’ when you only look at those 2 sentences. It isn’t satisfactory, if two patients in similar clinical situations ask for CPR to be attempted, and one is told ‘okay – we will attempt CPR if you want us to’ while the other is told ‘sorry – we are not going to attempt CPR’.

In 8.3, we can also find this:

A patient might insist that future CPR is provided - even when (for clear clinical reasons) the clinical team feel it to be an intervention which cannot provide clinical benefit and will not be successful. When a patient requests CPR following a discussion that clearly outlines very significant risks and burdens, the senior clinician must record fully the patient’s expressed wishes, alongside their own clinical views. When conflict exists and whilst further advice is sought, the interim position should normally be to call the emergency services or arrest team in an arrest situation, to consider CPR under current circumstances on arrival, as appropriate. … In such cases, a second opinion must always be offered and legal advice may become necessary with further discussion with the patient.

So far as I am aware, that ‘interim position’ of attempting CPR while further advice is being sought, and efforts are being made to see if the patient and clinicians can move to agreement, has been pretty-much accepted practice for many years. And we also have, earlier in the Policy in section 5.1.1:

‘If the clinical team is as clinically certain as possible that attempting CPR would not re-establish effective circulation and maintain breathing then CPR need not be attempted. … A patient cannot demand a treatment that is not clinically indicated. To provide CPR in such circumstances as described above would be futile. The decision is a clinical one centred on the clinical picture at the time. The position should be communicated to the patient (see section 4.3) and, with consent, to those close to them.’

The wording in 5.1.1 is what I have ‘historically’ found in policies about CPR – and it takes into account the Tracey ruling (see section 5.6 of the Policy).

ANALYSIS

Until I reached section 8.3 in THIS policy, the stress in everything I had read amounted to what is written in section 5.1.1 – in effect:

‘Doctors need not offer to attempt CPR if they are convinced that CPR could not restart the heart and breathing, but almost always the doctors should inform the patient of THEIR (the doctors’) decision to not attempt CPR.’

The guidance has always suggested (certainly since the Tracey ruling) that if the patient asks for CPR in that situation, a second opinion should be sought: logically, the second opinion can only be about the issue of whether CPR might be successful. A second opinion is a peculiar concept, if the patient has said ‘I accept that CPR almost definitely wouldn’t work – but I want you to try CPR anyway’.

What the Audit point to 8.3 says, is different. Since the Tracey ruling, doctors and nurses are in most cases required to say ‘we are not planning to attempt CPR if you arrest – we don’t think it could work for you’ at which point the patient might say ‘I want you to try CPR anyway’. Doubtless some patients, will say without any prompting ‘I want you to try CPR if my heart stops’. And, that Audit point in section 8.3 implies that THE POSITION OF THE POLICY is that CPR should be attempted if requested by the patient, in a situation when the clinicians predict the CPR attempt would fail:

‘It should be considered an “exceptional clinical event” to pursue a DNACPR position that is contrary to the expressed views of the patient.‘

I’m not entirely sure why it says “exceptional clinical event” in the sentence (possibly that is a term used within ‘audit of behaviour/events’) but when I read the sentence, it seems to me [as a layman who has been reading about CPR/DNACPR for a decade] the sentence can be rewritten as:

‘If a patient has requested CPR then it should almost always be attempted by clinicians who are aware of the patient’s request.’

This is ‘in contradiction’ to ‘CPR which would not work need not be offered’ but only in as much as THE POLICY [apparently – according to my analysis here] has a position that ‘CPR which would not work will be offered’. Then, the question is whether doctors and nurses in Wales, should follow the position of the Policy. What we are told about the Policy, is (from section 1 of the Policy):

‘… this DNACPR policy takes account of the recommendations set out in the Older People’s Commissioner for Wales ‘Protection of Older People in Wales- A guide to the Law’ document and the European Convention on Human Rights. … This policy applies to all NHS Wales staff and the care of patients of 18 years of age and over in all care settings within the remit of NHS Wales. … NHS Wales is responding to the need to introduce substantial improvements with regard to DNACPR decisions involving adults in order to achieve more appropriate patient-centred care. The focus is on respect for the wishes of individuals in order to facilitate the provision of appropriate care near the end of life and the need for discussions to take place in a shared and planned way, at an earlier stage, across all settings including the home and community. … The purpose of this policy is to provide a framework for professionals and NHS bodies in Wales to facilitate a consistent approach to decisions about the provision of CPR. Healthcare professionals (HCPs) involved in DNACPR decisions should familiarise themselves with this policy.’

I will add, in the context of that ‘second opinion’. If the first team are of the opinion that CPR couldn’t work, and a second clinical opinion amounts to ‘I think CPR might work’, then we are NO LONGER WITHIN THE REMIT OF section 8.3 (if CPR might restore life, then we should be in ‘the patient decides’ territory: or, the challenging ‘MCA Best Interests’ territory if the patient cannot make the decision). So that sentence in the Audit point of section 8.3, MUST BE in the context of ‘CPR which would almost certainly have a ‘bad clinical outcome’’: as the heading of 8.3 says ‘A clear request for CPR – when CPR is not likely to be successful or clinically indicated’.


mike stone 10/03/22

At the ‘instinctive’ level, my position on both withholding and attempting CPR is simple: let informed patients decide.

When my parents were dying, my position was that it was their life, and I would support their decision. At that level, if my dad said ‘I want them to attempt CPR even if they think it wouldn’t work’ then I would be for CPR. Ditto if my mum had said ‘If my heart has stopped, let me die’ - then I would be against CPR, irrespective of the probability of CPR working. So all of the nerdy stuff - ‘a verbal refusal of CPR cannot be a valid Advance Decision, but can it be ‘legally binding’ nevertheless?’, how sure can doctors be about the clinical outcome of a CPR attempt, etc - becomes a side-issue. ‘Inform the patient, then do what the patient wants’ would keep things simple. At the moment, in theory a patient can ‘enforce’ the ‘I don’t want CPR’ by means of a written Advance Decision (although even then, sometimes an ADRT refusing CPR will not work – see the PDF which can be downloaded from my first post in this thread). Currently, a patient’s ‘I want you to attempt CPR’ is much more awkward: if my ‘dying father’ was at home, and he said ‘I want you to attempt CPR’ then his GP could say ‘it wouldn’t work – I’m not going to attempt CPR’ and my sister could say ‘well, I am going to attempt CPR, because dad wants me to’.

I am writing in the context of ‘DNACPR documents’ - which are completed before a cardiopulmonary arrest. It isn’t a suggestion that if CPR is clearly impossible at the time of the arrest, it should be attempted: an extreme example would be that it makes no sense to ‘attempt CPR’ if death was caused by decapitation. But the arguments around DNACPR documents, usually involve the outcome-spectrum after a CPR attempt – not cases when, to use my phrase, ‘CPR is obviously impossible’.

As it happens, if more of the public were aware of the reality of the chest compressions which are usually (especially if you outside of hospital, and not connected to monitoring equipment) the first stage of CPR, I suspect most people who were ‘nearing the end of their lives’ would refuse CPR. I think many people would say ‘No thanks!!! Let me have a peaceful death’. On TV, chest compressions are unrealistically ‘gentle’: in reality, CPR can break ribs, and damage internal organs. If performed on a ‘very frail’ person, CPR itself could potentially temporarily restore life, but also cause so much damage that death within a few days or a week or so would be inevitable. One doctor, memorably tweeted while we were discussing the difference between CPR on screen and CPR in real life, ‘you don’t hear the ‘crunchy sounds’ as ribs break, on TV’.

There is also a bit of a paradox. It is conceivable, that a person who was ‘frail enough that CPR could not restore life’ could also still walk. Suppose such a person was still living at home. The GP might, the way the current ‘guidance’ works, in essence ‘make the person DNACPR’. But, if this person left home and collapsed on the street in cardiopulmonary arrest – essentially becoming ‘an ‘unknown but collapsed’ person’ - then 999 staff would be likely to attempt CPR.

I think, ‘inform the patient, and then do what the patient wants’ for CPR, would be the LEAST PROBLEMATIC approach. Not perfect – but better than what has been happening so far. The wording in section 8.3 of the Policy seems pretty good to me – it amounts to ‘normally, accept a decision expressed by the patient’:

‘It should be considered an “exceptional clinical event” to pursue a DNACPR position that is contrary to the expressed views of the patient.’

I was talking about section 8.3 to someone yesterday, and she introduced ‘… when the family ‘insist on’ every possible attempt to keep the patient alive’. I pointed out, that both my own online piece and the sentence in 8.3 are about a [presumably capacitous] patient having asked for CPR. ‘Best Interests’ situations, are more complex – but we could START WITH ‘this patient, while capacitous, had clearly asked for CPR to be attempted – that wish would apply in the situation of this arrest, and we have no reason to believe the patient has changed her mind’, and leave best interests until after everyone has agreed about what should happen if a patient wants CPR.


Carol Blackhurst 10/03/22

I lost my mum through a heart attack and they did CPR which got her heart going just she was but in to intensive care for 12 hours and we had to have the machine switched of I think it was a waste of time

Jan Charles 10/03/22

Mike
Why as a society are we so keen to take decisions for people. Have we forgotten that people are often able to make their own decisions. This is why we have been endowed with the ability to problem solve and and think laterally. Even those with limited capacity should be enabled to use their thinking processes whenever possible

Jan Charles 10/03/22

When I started nursing decades ago, I witnessed my first Cardiac arrest on a man in his 70.s This was his second one and he lived for another 6 weeks. After his first arrest he survived as a business man for 10 years
A member of my family signed a DNR form, and he took 10 days to die in agony as fluids were withheld after the first few days. The family attended him to give him mouthcare as the hospital staff did not bother- so in my opinion DNR consequences should also be considered

Jan Charles 10/03/22

Carol
Sorry to hear about your mum. Not a waste of time though. You tried and she may have understood even if you could not seem to effectively communicate. Just remember that hearing is usually the last sense to go.

Bless you for ever xx Jan

mike stone 11/03/22

Apologies.

In my previous post, I said that there was something about Advance Decisions in the PDF you can download from this thread. In fact, there is a short discussion of ADRTs in the PDF you can download from:

https://www.dignityincare.org.uk/Discuss-and-debate/download/449/

mike stone 11/03/22

Hi Carol,

I know of someone on Twitter, whose mum arrested and CPR was attempted and the person I knew initially 'saw it as a miracle'. Then, her mum was in hospital for about a week, a lot of argument about things such as 'brain damage' and signs-of-recovery took place between the family and the doctors (in essence the doctors said the lady was 'brain dead' - the daughter thought her mum was showing signs of awareness), and eventually the mum died with the daughter being convinced 'the hospital wasn't trying to keep mum alive'. Having originally thought of 'successful CPR' on her mum as a miracle, the daughter now regards it as being disastrous, and believes that CPR should never have been attempted on her mum. The daughter was deeply upset by how her mum died, and by how the hospital's doctors and nurses behaved: she made a series of complaints, and the whole thing, to use my phrase, 'pretty-much wrecked the daughter's life'.

Hi Jan, don't get me started on the withholding of fluids from 'the dying'! At least post-Neuberger (the review - of the LCP) the instruction is that if a capacitous person is dying, and wants to drink after having been told of the risk of fluid getting into the lungs, the clinicians are required to supply drinks. It seems that before the Neuberger review, some patients were drinking water from flower vases in desperation - totally unacceptable!

As for your other question - 'Why as a society are we so keen to take decisions for people' - I honestly don't know. I suspect the professionals are often 'worried about being blamed'. The law has changed - and is still changing, at least in terms of being 'clarified by' judges - away from 'society making decisions' and towards 'decisions based on the patient's individuality' [if the patient lacks capacity], but there is still a lot of 'work to be done'.

Jan Charles 11/03/22

Mike Mouthcare is just that. If neglected then a patient can have a. nasty infection which causes a great deal of discomfort, We need to remind ourselves that we are nurses or carers but not the gods that some palliative care nurses seem to think they are. I dread ever having to enter such a establishment where the dying are sometimes treated as non-beings. I remember being taught the need for TLC
Jan

mike stone 12/03/22

Hi Jan,

Yes, you make a good point about Mouthcare. But what the Neuberger Review of the LCP seemed to reveal, was distress among relatives not of the absence of 'mouthcare', but of the fact that dying-loved-ones clearly wanted to drink, when drinking was being withheld and not allowed by the clinicians.

There is a big difference between keeping the mouth and lips moist, and letting a patient who is clearly 'desperately thirsty' actually drink.

mike stone 15/03/22

I have been pondering how to fit the pieces together, if ‘the NHS’ wanted to offer CPR to patients who had clearly requested that CPR should be attempted ‘even when CPR almost certainly would not be successful’. And – as of this morning (it is possible that when I wake up tomorrow morning, a useful insight will have struck overnight!), what follows is my analysis of the situation.

We need to fit together:
1) That the position has always been that clinicians cannot be forced to offer ‘futile’ treatments. The meaning of ‘futile’ has been changing over time – and for CPR, I think we should now take ‘futile’ to mean ‘the heart and breathing WOULD DEFINITELY NOT be restarted by CPR’;
2)An assumption – here – that ‘the NHS’ would indeed like to attempt CPR if while capacitous a patient had clearly asked for CPR to be attempted, in a situation when the clinicians had told the patient that the outcome of CPR would almost certainly be ‘a dire clinical situation at best – but much more probably death (i.e. most likely that CPR would not restore life at all)’.

I think, it is crucial to this analysis, that a DNACPR form is completed BEFORE a cardiopulmonary arrest occurs .

I don’t see how ‘the NHS’ can offer CPR which would almost certainly fail to some patients, but not to other patients if the patients are in clinically-comparable situations: and they would be, because the crucial thing here isn’t why CPR is predicted to almost certainly fail, but the prediction itself. If two different clinical teams are saying to their patients ‘We feel as certain as we can be, that if you arrested and we attempted CPR it would not keep you alive’ then it would be ‘discrimination’ if one team said ‘so we will not attempt CPR, even if you want us to’ and the other team said ‘okay, if you want us to attempt CPR now you have been informed of its likely outcome/s, we will attempt CPR if you arrest’. Basically, if ‘the NHS’ is offering to attempt CPR when it would almost definitely not keep the patient alive, then the offer MUST BE MADE TO ALL PATIENTS.
So, now I must return to 1). And this is where the fact that DNACPR documents are created BEFORE an arrest comes in. If we interpret ‘futile’ as I have suggested, to mean DEFINITELY would not keep the patient alive, then there will almost always (this might in fact be ‘always’ – but I’m not absolutely certain of that) be a degree of uncertainty in the clinical teams prediction that CPR would not keep the patient alive. But, at the time when CPR would be attempted, it IS POSSIBLE to sometimes see reasons why CPR DEFINITELY could not restore life: for example, decapitation or a massively-traumatic chest injury.
So, the move to ‘attempt CPR which is PREDICTED to ALMOST CERTAINLY not restore life if the patient wanted you to attempt CPR’ as the pre-arrest position, does NOT conflict with ‘a clinician cannot be forced to attempt CPR if it clearly could not restore life as a clinical position FORMED AT THE TIME OF THE cardiopulmonary arrest’. What we would be removing, is the justification to not attempt CPR because of a previous clinical prediction about its likely success. The position would amount to ‘If the patient had asked for CPR to be attempted, then at the time of the arrest a clinician should attempt CPR if the clinician would attempt CPR on a person found in arrest on the street’.
Whether this change requires merely the ABSENCE OF a DNACPR document – the clinicians actively involved with the patient would have agreed to attempt CPR if they were present at an arrest, and usually ‘non-previously-involved’ clinicians default at the time of an arrest to attempting CPR – or if it needs what amounts to a ‘This patient wants you to attempt CPR – so you should attempt CPR’ form, I’m not sure?

Comments welcome – including any suggestions to improve on my wording here:

The position would amount to ‘If the patient had asked for CPR to be attempted, then at the time of the arrest a clinician should attempt CPR if the clinician would attempt CPR on a person found in arrest on the street’.