Introduction
Deciding whether or not it is appropriate to attempt cardiopulmonary resuscitation (CPR) often evokes strong emotions in patients and their families and within the multidisciplinary team. When there is any element of doubt, the default position in most healthcare settings is to attempt to preserve life, although this has been questioned; some clinicians have suggested that there should be an opt-in policy for CPR. This chapter focuses on the ethical aspects of the decision-making process and the importance of effective communication. However, it is crucial that all such decisions are made within the law of the appropriate country or state. For illustration purposes, reference will be made in this chapter to some aspects of the law that applies in England and Wales (e.g. The Mental Capacity Act 2005). Healthcare professionals have a responsibility to be aware of the law that applies in their place of practice; there are differences in some aspects of the law in other parts of the UK and in other countries.
For the purposes of this chapter the terminology used for a decision not to attempt CPR will be DNACPR (Do not attempt cardiopulmonary resuscitation). Box 22.1 illustrates the range of terminology that can be found.
- DNR (Do not resuscitate)
- DNAR (Do not attempt resuscitation)
- DNACPR (Do not attempt cardiopulmonary resuscitation)
Ethical principles
There are considered to be four key principles related to medical ethics decision-making in addition to sanctity-of-life doctrine. These are shown in Box 22.2.
- Autonomy (self-determination that is free from controlling interferences by others preventing meaningful choice)
- Beneficence (acting in the person’s best interests)
- Non-maleficence (doing no harm)
- Justice or equality
Autonomy is a key principle for DNACPR decisions. If an adult (a person aged 18 years or above) chooses to refuse CPR and is considered to have capacity for that decision, their view must be respected even if it appears extreme. If an adult is not able to make a decision, for example when they are unconscious, then the decision maker still needs to consider any previously expressed views. An example of this is an Advance Decision, which gives an adult the opportunity to record their wishes regarding their future care in case they become unable to make decisions for themselves and may include a statement refusing resuscitation. This document is legally binding in England and Wales but must be signed and witnessed and state specifically that it should apply even if their life is at stake.
Another way that people have tried to inform others of their wishes regarding CPR is to have a ‘Do not Resuscitate’ tattoo. From an ethical and legal point of view this presents difficulties as it is impossible to know whether this tattoo represents a valid advance decision at the time of a cardiac arrest. The person may have changed their mind or the decision may be based on a prognosis that is out of date. Additionally patients and the public may not always have a clear or realistic understanding of their diagnosis or the benefits, burdens and risks of CPR, as the public’s knowledge about the clinical complexities may be limited (General Medical Council (GMC) Guidance 2010).
Applying ethical principles
Balancing the principles of beneficence and non-maleficence and helping people to understand that balance in using their autonomy to make decisions is often difficult. Bringing someone back to life from cardiorespiratory arrest is clearly in their best interests if they recover to a quality and duration of life that they regard as worthwhile, whereas resuscitating someone who then has to endure severe disability or suffering and a quality of life that they find intolerable has done more harm than good. In helping patients and those close to them with CPR decisions, it is crucial to explain the potential risks associated with CPR as well as the possible benefit, and the lack of certainty about the outcome. Finally to incorporate justice and equality in CPR decisions it is important to ensure that these decisions are not influenced by factors such as age, gender, race or religious beliefs. Of these, perhaps age is the most challenging but rigorous attention to the other three principles, irrespective of age, will help to ensure that appropriate decisions are made.
When are decisions about CPR appropriate?
Planning in advance for anyone at risk of a cardiorespiratory arrest (e.g. those with life-limiting or life-threatening disease) is an important part of clinical care. This should include decisions about CPR (Joint statement by the British Medical Association (BMA), Resuscitation Council (UK) (RCUK) and the Royal College of Nursing (RCN) 2007) as well as other palliative care decisions such as symptom control and psychological, cultural and spiritual wishes. This is relevant for many people in the community as well as those admitted to hospitals and other healthcare institutions.
A decision not to attempt CPR may be considered in three broad sets of circumstances as shown in Box 22.3.
- CPR will not re-start the heart and breathing
- CPR is refused by a patient with capacity or there is a valid Advance Decision in a patient who lacks capacity
- CPR is considered not to be in the patient’s best interests as the risks of CPR outweigh the benefits
When CPR will not re-start the heart
CPR will not be successful in re-starting the heart and breathing if a cardiorespiratory arrest is part of the dying process in a terminal condition and so should not be attempted. CPR in these circumstances will result in a loss of dignity and hinder a good death. The term medical futility has been used to describe this situation; however ‘futility’ is open to a number of subjective interpretations and so is probably best avoided.
Refusal of CPR
This arises when, irrespective of the likelihood of successful resuscitation, the person chooses to refuse CPR. In the case of a person without capacity, that refusal would have to have been recorded as a valid Advance Decision to refuse treatment. To be valid, an Advance Decision must apply in the specific circumstances present at the time of the event. For example, it would be appropriate to provide immediate treatment to relieve airway obstruction due to choking, if this situation had not been foreseen and specified in the Advance Decision.
There may also be situations where suspension of a DNACPR decision (including an Advance Decision) requires careful consideration. This may become appropriate when a patient is undergoing a procedure such as cardiac catheterisation or a surgical operation and the chances of immediate, effective treatment of cardiorespiratory arrest are high. The Royal College of Anaesthetists advises that all DNACPR orders should be reconsidered in these circumstances, and decisions made about what resuscitation is appropriate for each individual, including CPR. Once again, autonomy must be paramount in these decisions, and some patients with an Advance Decision will want it to remain in force in these circumstances. Box 22.4 describes situations when a review of the CPR decision may be appropriate.
