To Resuscitate or Not to Resuscitate?

Resuscitation is not like it is in Holby City

Do Not Resuscitate

The subject of resuscitation is, by definition, an intensely emotive one, not helped by the myriad of acronyms that all mean pretty much the same thing – if your heart stops, your medical team will not try to restart it.

Do Not Attempt Resuscitation (DNAR)

In 2005, The American Heart Association replaced Do Not Resuscitate (DNR) with Do Not Attempt Resuscitation or Do Not Attempt Cardiopulmonary Resuscitation (DNACPR).

This change underlined that there is no guarantee resuscitation will be successful, and the emphasis of the decision should be on whether or not it should be attempted in the first place – especially given the distinct possibility that it may do more harm than good.

It is a common misunderstanding that Cardiopulmonary Resuscitation (CPR) will keep patients alive and living as they were before the procedures; it is largely unknown that it is an invasive and sometimes violent procedure that, in some cases, may cause injuries such as punctured lungs, broken ribs, and bruising.

Even if the attempt is successful, it can, in fact, do more harm than good, and it is not clear just how these injuries may affect the quality of the person’s remaining life. Patients who do survive CPR may not regain consciousness, can suffer brain damage, or may die soon afterwards, especially if they have multiple underlying conditions. The exception is in cases where people who are generally fit and well experience a sudden problem, such as a heart attack, and are treated rapidly.

Overall, CPR can be successful in 10-20% of cases, but this drops to less than 2% for people with long-term conditions like cancer, organ damage, or other chronic illnesses**.

It is important to mention that any DNR form only covers CPR – other treatments and care can be given to ensure patients are pain-free and comfortable. It does not refer to other aspects of care e.g.: analgesia, antibiotics, suction, treatment of choking, treatment of anaphylaxis, etc, which are sometimes loosely referred to as ‘resuscitation’. To avoid confusion, the phrase ‘do not attempt cardiopulmonary resuscitation’ should be used, rather than ‘do not resuscitate’ or ‘do not attempt resuscitation’.

So, who makes the decision whether to resuscitate or not?

In principle, it is a decision is made by you and your doctor or healthcare team. However, as it is a medical treatment, the decision can be made by your doctor without your consent.

In 2014, the Court of Appeal ruled that people with mental capacity have the legal right to be notified when a do not attempt cardiopulmonary resuscitation order is placed on their medical records, unless it is believed that this knowledge would cause physical or psychological harm.

Notwithstanding this ruling, during the first wave of the Covid-19 pandemic, the longstanding, inappropriate and often blanket use of DNR notices for individuals in care homes, and people with a learning disability, was exposed, highlighting the need for greater protections to be put in place.

Advance Decision [to Refuse Treatment] (ADRT)

If you are no longer able to make the resuscitation decision, the medical team must check whether you have an Advance Decision, also known as an Advance Decision to Refuse Treatment or Living Will. An Advance Decision is  legally binding if it complies with the Mental Capacity Act. It is a way to state the specific medical treatments that you want to refuse in future. It will be used if you are unable to make decisions for yourself or communicate them to others – in other words, if you lose your mental capacity.

Lasting Power of Attorney for Health and Welfare (LPA)

A further way to guard against the possibility that you may no longer have Mental Capacity to make your medical wishes known, is with a Lasting Power of Attorney for Health and Welfare. This is providing you have given your chosen Attorneys the right to make your decision on life sustaining treatment.

Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)

In March 2017, The ReSPECT Process was made public. This is a two-sided form, which allows patients, in conjunction with their medical team, to indicate the extent to which they wish to prioritise sustaining their life, or prioritise being comfortable and pain-free.

The decision to resuscitate or not is both an extremely personal and intensely practical one. If you have made this decision, it is crucial that it is widely known to your family and medical team and the form is readily available – not buried amongst a pile of papers on your desk.

Scotland

The legal standing is similar to that in England and Wales. Both in Scotland and Northern Ireland, an Advance Decision is known as an Advance Directive and is not covered by an act of law, but should be taken into account when decisions are being made on your behalf.