Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) - integrated adult policy: guidance
Guidance on decision making and communications policy in relation to the NHSScotland Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policy.
SUCCESS AFTER CPR
Information from large cardiac arrest surveys in North America, Europe and the UK have shown that 80% of cardiac arrests occur outside hospital - 90% of these will result in death (Young et all 2009). Survival to 1 month was 2.3% in those who presented in a non-shockable rhythm (Hollenberg et al 2008). This presentation is more likely with chronic life limiting conditions. When cardiac arrest occurs in hospital, 13-17% survive to hospital discharge (Ferguson et al 2008; Peberdy et al 2003).
Success after CPR may be measured by survival, but more meaningfully by a return to a quality of life that the individual would find acceptable. Where a patient already has a life limiting illness and distressing symptoms due to chronic organ failure, the best that could be hoped for is return to that state or more realistically worse. During CPR rib fractures and hypoxic brain injury are a significant risk. There is a great potential for inflicting distress and suffering to many patients in a questionable attempt to prolong poor quality survival of a few. The likelihood of success as measured by survival needs to be viewed in this context. We should also recognise that the chances of survival after cardiac arrest will be much lower in patients with life limiting conditions than the unselected populations quoted in the literature above. Intensive Care is not an option which can change outcome where the cause of arrest was underlying life limiting or terminal illness which cannot be improved. In patients with significant life limiting illness the balance of potential benefits and burdens of any intervention has to be considered before any advance decision can be made.
It is not possible to give all encompassing advice. Individual clinicians should use their knowledge of their patient and natural history of their illness(es) to decide when the quest for medical success is outweighed by the risk of unacceptable suffering and indignity in the attempt.
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