Advance decisions about CPR treatment
Advance decisions about CPR can be difficult and can cause considerable emotional distress but, when discussed in the context of goals of care and choices about available treatment options, they can also be extremely reassuring and a huge relief for some patients. There is evidence that patients experience conversations about DNACPR as positive and empowering when they happen within the context of wider discussions about emergency care planning and end of life care goals ( http://www.palliativecarescotland.org.uk/content/publications/23.-Patient-and-family-experiences-of-DNACPR-discussions---an-integrative-review-of-the-literature.pdf). The appropriateness of CPR should always be considered on an individual patient basis. There is never a justification for blanket policies to be in place. An advance decision that CPR should not be attempted can be made if either of the following is relevant:
A patient makes a competent advance refusal
- When CPR is not in accord with the recorded, sustained wishes of the patient who has capacity for that decision.
- When CPR is not in accord with a valid applicable advance healthcare directive (living will). A patient's informed and competently made refusal which relates to the circumstances which have arisen should be respected.
CPR treatment would not be of overall benefit for the patient
- When a patient's condition indicates that effective CPR would not be successful in achieving sustainable spontaneous breathing and circulation.
- When the patient lacks capacity and the healthcare team, in discussion with the patient's relevant others, agree that the benefits of medically successful CPR are likely to be outweighed by the burdens of that treatment, and/or that they are as certain as they can be that the patient would have regarded the quality of the sustainable life that is likely to be achieved as unacceptable.
When CPR may be successful it is important to assess whether the patient has the capacity to be involved in a decision about the overall benefit of such a treatment. If capacity is present, the issue should be broached with the patient in the context of their individual goals of care and exploration of their wishes for realistic emergency treatment options and end-of-life care choices. Where possible the patient should be asked whether they have thought about these issues and would wish further discussion. If the patient declines, then it is appropriate to make the decision without consulting the patient further. It would be appropriate to ask the patient if there is anyone else they would wish to be consulted and also to establish if they would or would not wish to be informed of any care decision that is reached. The importance of clear documentation of all of these discussions cannot be emphasised strongly enough.
If the patient does not have capacity for the CPR decision, then the principles of the Adults with Incapacity (Scotland) Act 2000 apply  . Where CPR might be successful in achieving sustainable life, a decision about whether the benefit of CPR would outweigh the harms and burdens for that patient must be discussed and agreed between that healthcare team and the patient's relevant others. Where there is a legally appointed proxy decision-maker (welfare attorney or welfare guardian) they must be involved in the decision-making process. Relevant information should be shared with those close to the patient (See Appendix IV).
Care should be taken in assessing capacity, and a specialist assessment may be helpful. Where a person's communication may be impaired, they should be provided with whatever assistance may be needed to assist communication. Further guidance is available in Chapter 3 of the Mental Welfare Commission's guidance document on Consent to Treatment. 
Even if a person does not have capacity, attention should be paid to their past and present wishes, and proper efforts should be made to establish these.
Email: Elizabeth Gourlay, firstname.lastname@example.org