Policy responses and statements

Name of organisation:

British Medical Association

Name of policy document:

BMA/RCN/Resuscitation Council - CPR Guidance for consultation

Deadline for response:

15 August 2007

Background: Why policies are needed:

Cardio-pulmonary resuscitation (CPR) could be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying so, theoretically, CPR could be attempted on every individual at the time of their death. However, for every person there will come a time when death is inevitable, so it is essential to identify patients for whom cardio-respiratory arrest represents a terminal event in their illness and in whom attempted CPR is inappropriate because it will not be effective. Inappropriate CPR may subject people to an undignified death, may prolong suffering in some cases. It is crucial also to identify those patients with capacity who state clearly that they do not want CPR to be attempted. Capacity refers to the everyday ability that individuals possess to make decisions or to take actions that influence their life. Patients over 16 years of age are presumed to have capacity to make decisions for themselves unless the contrary is proven. For those who lack capacity it is equally important to ensure that decisions are made that comply with the law, in that they are in the best interests of the patient.

All establishments that face decisions about attempting CPR, including hospitals, general practices, residential care homes and ambulance services, should have a policy about CPR attempts. These policies must be readily available to and understood by all relevant staff.

The purpose of these guidelines:

Health professionals are aware that decisions about attempting CPR raise very sensitive and potentially distressing issues for patients and people emotionally close to them. Some health professionals do not find it easy to discuss decisions about CPR with their patients, but this must not prevent discussion. The guidelines that follow identify the key ethical and legal issues that should inform all these decisions. These basic principles are the same for all patients, in all settings, but differences in clinical and personal circumstances make it essential that all CPR decisions are made on an individual basis.

These guidelines do not address all the complex clinical considerations that healthcare teams face. The guidelines do not distinguish between basic and advanced CPR because the underlying ethical and legal principles that govern decision-making are the same. The guidelines provide the general principles that allow local CPR policies to be tailored to local circumstances. Local policies may also contain more detailed guidance than can be provided here; this may include specific information about the allocation of individual responsibilities.

COMMENTS ON
BRITISH MEDICAL ASSOCIATION
BMA/RCN/RESUSCITATION COUNCIL - CPR GUIDANCE FOR CONSULTATION

The Royal College of Physicians of Edinburgh is pleased to respond to the British Medical Association on the CPR Guidance for consultation, which the BMA has produced jointly with the Resuscitation Council (UK) and the Royal College of Nursing.

General

The information about the poor outcome of CPR is important because decisions to prolong life are being made without this knowledge. It would be worth having the statement of outcomes at the beginning of the document, and not just in the middle of the document in section 7.

Perhaps there should be a section on discussions with relatives of patients who do have capacity, so that the document is more complete, although perhaps that should be self evident

Executive summary

This could be clearer in some areas and, indeed, more concise. It should state that the reasons for the decision must be clearly documented in all cases, as per section 14.

Under the second heading, ‘It is not necessary to initiate discussions about CPR with all patients’, the English in the 2nd bullet point could be clearer, as it has “not” twice in the same sentence.

Consultation question box, page 4

Is it really appropriate, with the recognised poor outcome in this phase of illness, to consider CPR? Should it not be recommended that, except in certain circumstances, this is discussed with patients? However, we would then have to mention mode of death as in the opening paragraph of the Introduction, ‘Why policies are needed’. This is important to avoid unnecessary CPR.

The College agrees with the 4th category, but we would emphasise that the healthcare team's role in this decision can usually be performed in advance.

The last sentence would have to say a ‘few weeks’, rather than ‘days’ to give useful help.

Section 6.2

Consideration could be given to re-emphasising where final responsibility for this lies and what support a team may have for these clinical decisions, as this may help to prevent differences of opinion with the patient or, indeed, relatives.

Section 7.1

Paragraph 2 should emphasise making this decision with the patient as early as possible, for example, in primary care or out-patient clinics ie before a crisis.

Communicating decision p18

It is clearly important that CPR decisions are clear to all parties. While the Lothian 'method' may have merits, it also has potential problems. It is most suited to patients with terminal disease and short life expectancy.

For other groups of patients, such as those in acute care/ITU who recover or who have underlying long term conditions, the situation may be more dynamic and the question of locating a piece of paper within large volumes of notes, or knowing whether it has been rescinded, may become less clear. We would recommend caution in promoting so few examples.

In general, the College feels that this is a very good document.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[15 August 2007]