In June 2012 a critical report was published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) highlighting the inadequacies in cardiopulmonary resuscitation (CPR) practice in hospitals. The study was carried out on 585 patients who suffered from a cardiac arrest during their admission to hospital, focusing on how they were treated before, during and after the cardiac arrest event.
This article examines the criticisms and recommendations raised about the CPR decision making process. The report also considered what actions could be taken to prevent cardiac arrest from occurring in the first instance, and the aftercare patients received following the event. These two elements are outside the scope of this article, although the full report can be found on the NCEPOD website.
The report highlighted the disparity between public and professional perception of the outcome of CPR. Media melodrama and the lay press are largely responsible for the public's overly optimistic view of the survival rate of CPR, with many believing it is as high as 50%. By contrast, the professional view puts the likely survival rate at 10-20%. What is perhaps more concerning is the lack of awareness about the vigorous physical process that CPR involves. Even where CPR is successful, the patient is by no means guaranteed the same quality of life they had prior to the cardiac arrest.
The report identifies that CPR is too commonly the default position. Patients need to be given all the information possible to determine whether or not they wish to receive CPR in the event of a cardiac arrest. Importantly, this information must be given as early as practicable to avoid a professional having to take that decision in an emergency. Consideration must always be given to the patient's best interests. Therefore if a resuscitation attempt would be futile it should not be attempted.
The report sets out three main recommendations relating to CPR status and the resuscitation event:
1. Initial assessment - CPR status should be considered and recorded for all acute admissions, ideally during the initial admission process but certainly at the initial consultant review. Where CPR is considered inappropriate, consultant involvement must occur at that time.
2. Resuscitation status - healthcare professionals must understand that a ‘Do Not Resuscitate’ document does not preclude a patient from being treated generally. Healthcare professionals must also understand that in the event of a cardiac arrest of any patient, CPR attempts may be futile and unwarranted.
3. Resuscitation attempt - each hospital should ensure that there is an agreed plan for airway management during cardiac arrest e.g. bag and mask ventilation or tracheal intubation (if within the competence of the team responding).
Each of these three recommendations identifies a need for a clear management plan for a patient. Patients must be given as much information as possible to enable them to take this difficult decision, and, where possible and appropriate, family support should be utilised.
Best interests decisions
Another complexity of this area is the regular requirement of healthcare professionals to provide care for patients who lack capacity to determine whether or not they wish to receive CPR in the event of cardiac arrest. This may be due to the nature of the injury (e.g. unconsciousness) or the mental status of the patient (e.g. dementia).
In such circumstances the healthcare team needs to carry out a capacity assessment and, if this determines the patient lacks capacity, can take any decision in the best interests of the patient, provided it is done so in line with the Mental Capacity Act 2005.
Recording the decision
Ensuring that the decision is properly and clearly documented is perhaps just as important as ensuring that a decision is made. Carrying out CPR on a patient who has opted against such an intervention may leave a healthcare professional exposed to criminal allegations of assault, as well as potential sanctions from professional bodies.
Equally ‘Do Not Resuscitate’ documentation must be visible and accessible to healthcare professionals. How this is achieved does vary between organisations. However Trusts must ensure that appropriate policies and processes are in place, and are unambiguous.
All staff that will be involved in the CPR process should receive appropriate training.
How can Bevan Brittan help?
Our Healthcare team has a wealth of experience in providing legal support to healthcare professionals faced with these difficult and challenging circumstances.
Whether you need assistance in drafting or reviewing your
policy, advice or training to support you and your staff, we are
able to assist.