Consideration of the outcome of CPR
It is not unusual for patients and their relevant others to have unrealistic expectations of the success of CPR and also its consequences. Where CPR is a treatment option, realistic, honest and individualised explanations of the traumatic nature of the treatment and the expected outcomes in terms of survival to discharge should be included in discussions with patients and those close to them. This information is an essential part of informed, shared decision-making.
Consideration of the outcome of resuscitation should be as realistic as possible and should take into account the clinical condition and functional status of the patient, the likely cause of the anticipated arrest, and also the environment in which the patient is being cared for. Making this complex clinical judgement is a core responsibility of every experienced clinician.
A clinical DNACPR decision should be based on the judgement that effective CPR will not achieve sustainable spontaneous breathing and circulation for the individual patient rather than any judgement about the quality of the life that may be achieved. It is recommended that such clinical decisions be made considering the circumstance of a prolonged resuscitation. There may be some situations, such as critical or intra-operative care, in which the likely cause of the cardiac arrest is easily treatable and the advance decision-making should therefore reflect this. It may be appropriate to temporarily suspend a documented DNACPR decision for the duration of an operation or procedure where a potentially reversible cardiac or respiratory arrest can be anticipated. Where the documented DNACPR decision is a clinical one made because CPR will not be successful, the reasons why this decision would not apply to the peri-operative period must be carefully considered and sensitively shared with the patient and their relevant others. Where a DNACPR decision is documented because the patient would not wish to have CPR, the patient's advance refusal must be carefully considered in the context of a peri-operative cardiac arrest and a plan agreed with them and/or their relevant others. Patients with a DNACPR decision in place must be referred to the anaesthetist as early as possible prior to a planned operative procedure to enable these discussions to be held and fully documented. The Association of Anaesthetists of Great Britain and Ireland ( AAGBI) has published specific guidance on management of CPR decisions in the perioperative period (see www.aagbi.org/publications/publications-guidelines/A/F).
Email: Elizabeth Gourlay, firstname.lastname@example.org