It can take a considerable amount of time for doctors to explain resuscitation issues to patients, and for clinicians to understand the wishes of the patient - such discussions are usually sensitive, exploratory and wide-ranging, and often require several conversations. Modern hospital practice usually involves shift work, and often there are several different doctors looking after each patient. It is essential that the clinical team makes time to discuss resuscitation decisions with each patient, and that there is a consistent response from each clinician.
Almost every hospital has introduced Do Not Attempt Resuscitation policies, procedures and forms, and clinical staff have become better at discussing death and resuscitation with patients. For those involved in hospice care and palliative care teams, however, the management of death goes well beyond the issue of whether to resuscitate or not. An alternative, more positive way of thinking about death in people with advanced disease is labelled Allow a Natural Death’ (AND).† Allowing a natural death simply means not interfering with the dying process whilst providing care that will keep the patient as comfortable as possible. Allow a Natural Death orders are intended for terminally ill patients who are being cared for in hospices, care homes or at home, but there is no reason why these should not be applied to patients in acute hospital wards as well. The NHS Gold Standards Framework enables generic care providers, such as primary care, care homes, and palliative care settings to deliver a gold standard of care for all people nearing the end of their life, † and there is an ‘Allow a Natural Death’ form on their website.* The Avon, Somerset and Wiltshire Cancer Services also have an ‘Allow a Natural Death’ form on their website.† Dignity in Dying is an organisation dedicated to ensuring choice about where to die, who is present during death and treatment options, and provides access to expert information, good quality end-of-life care, support for loved ones and carers, together with advice on symptoms, and pain relief † A decision to ‘Allow a Natural Death’ should be communicated in writing by professional clinicians to the local Ambulance or Emergency Services dispatch control centre to avoid resuscitation if that person should unexpectedly collapse. However, at present there are no national arrangements or systematic ways of communicating DNAR orders across all potential healthcare settings. We already use national NHS consent and DNAR forms in our hospitals, so it should not be difficult to extend this and register such forms with the emergency services; Advanced Directives or “Living Wills” could also be included. Of course, a DNAR form or Advanced Directive would need to satisfy the various legal requirements of a written document: it must be signed by the patient and a witness, the patient must have demonstrated adequate mental capacity to make the decision at the time, and the order or directive would have to be applicable to their current illness or condition. Safeguards against fraudulent entries and the influence of overzealous relatives would be necessary - for example, the witness and co-signatory might be a person who knows the patient in a professional capacity, such as their GP, solicitor, priest or minister. Arrangements could be made for patients to reregister or renew these documents annually. Obviously, legal and confidentiality safeguards would also be required with regard to the sharing of the information contained in these forms across different emergency services and healthcare organisations. Such forms could be stored electronically and shared online so that when an emergency call is received about a patient with a DNAR order or Advanced Directive, this would immediately be flagged up and the contents notified to the emergency controller.
Clinical staff are not obliged to offer resuscitation to every patient; doctors do not have to offer or provide treatments that are futile. If a patient has an advanced terminal illness with no realistic chance of improvement, doctors do not have to undertake resuscitation in the event of a cardio-respiratory arrest; it would be considered unethical. However, sometimes a patient or their family cannot accept that unavoidable death may be close, and insist that ‘everything must be done’. Where there is a persistent discrepancy between the views of the patient or their family and the clinical staff, it is good medical practice to seek additional opinions and advice from experienced doctors not directly involved in the case.
The General Medical Council in The United Kingdom has published guidance on ‘Treatment and care towards the end of life: Good practice in decision making’.* This guidance is based on long-established ethical principles, which include a doctor’s obligation to show respect for human life; to protect the health of patients; to treat patients with respect; and to make the care of their patient their first concern. Patients who are approaching the end of their life need high-quality treatment and care to help them to live as well as possible until they die, and to die with dignity. The guidance identifies a number of challenges in ensuring that patients receive such care, and provides a framework to support doctors in addressing the issues in a way that will meet the needs of individual patients. It emphasises the importance of communication between clinicians and healthcare teams when patients move between different care settings (hospital, ambulance, care home), and during any out-of-hours period. Failure to communicate relevant information can lead to inappropriate treatment being given or failure to meet the patient’s needs.
Mental capacity to decide on resuscitation
Decisions relating to resuscitation cannot be made by patients who are not mentally capable of understanding their condition, the obvious example being when the patient is unconscious. A patient must be able to understand, retain, and weigh information about themselves, and be able to communicate in some form, in order to make a rational decision about their medical care.
There are variations in different jurisdictions regarding the legal tests and requirements to determine whether a patient has the mental capacity to make such decisions, but the general medical principles are common to most circumstances. In order to demonstrate effective mental capacity, a person should be able to understand what the medical treatment is, its purpose and nature, and why it is being proposed; as well as comprehending its benefits, risks and the alternatives; they must understand, in broad terms, what will be the consequences of not receiving the proposed treatment; be able to weigh the information in the balance to arrive at a choice; retain the information for long enough to make an effective decision; and make a free choice without external pressure. Different medical treatments may require different levels of mental capacity; for example, the consent process for having a blood sample taken requires a lower degree of weighing and retaining information, compared with the consent process for major, life-threatening cardiac or abdominal surgery. If a patient lacks the mental capacity to make a decision about their care, this should be noted in their medical records, and the clinical reasons for it.
If a patient lacks adequate mental capacity, then the decision must be made for them in their best interests and urgent medical interventions can be performed, particularly in the case of emergency or life-saving treatments. In the case of serious procedures to be done without consent, it is good medical practice to consider alternative, less invasive treatments; to discuss treatment with all members of the healthcare team; to discussing treatment with the patient as far as possible; to consult with other healthcare professionals involved with the patient’s care (for example, their general practitioner); to consult relatives, partners and carers; to obtain further opinions from experienced doctors if the patient or their family do not agree with the proposed treatment; and to ensure a record is made of the discussions and any decision taken.
Again, there are variations on the legal requirements in different jurisdictions. Good medical practice would include consultation with relatives, partners and carers to ascertain what the expected wishes of the patient might be. In England and Wales, the Mental Capacity Act of 2005 has brought a legal obligation for clinicians to take into account the views of anyone named or appointed with power of attorney by the patient for this purpose, their carers, or any deputy appointed by a court.*
Initial
decision to resuscitate
In an unexpected or out-of-hospital cardiac arrest, when the patient cannot consent to treatment, the assumption has to be that resuscitation should be performed. Death can be verified by any appropriately qualified person, but this is usually done by a doctor, and in the United Kingdom only a doctor who has provided care during the last illness and who has seen the deceased within fourteen days of death or after death can sign a death certificate. If someone is found to have collapsed and died, the emergency services are still obliged to attempt resuscitation as they cannot in general immediately ascertain the underlying condition of the victim. Of course if a person has been dead for some time, for several hours or longer, death will be obvious and resuscitation attempts will not be appropriate.
Age itself should not be a deciding factor when discussing whether to resuscitate someone who has collapsed, when discussing whether to continue resuscitation attempts, or when discussing whether a patient would wish to be resuscitated or not from a cardio-pulmonary arrest. In general, the success of any medical treatment decreases with age, but there is no specific cutoff point concerning the success of resuscitation from cardiopulmonary arrest. Furthermore, clinical policies should not be ageist in terms of specifying treatments that are not provided to people over a certain age, unless there is very good medical evidence to suggest a lack of benefit. In the medical literature about resuscitation, there is no evidence that the outcome is dependent on being under a certain chronological age, or that failure occurs over a certain age. The benefits of most medical treatments depend on the general condition of the patient, therefore discussions about the value or futility of resuscitation should be based on that rather than the patient’s chronological age.
This is a reason why the most useful information when deciding whether to undertake or continue cardio-pulmonary resuscitation is the medical history. If, for example, a patient has presented with an exacerbation of breathlessness from chronic, extensive and end-stage respiratory failure, uses home oxygen and is house-bound as a consequence of their condition, then resuscitation from a cardiorespiratory arrest is less likely to be successful, and the prospect of a full recovery is unlikely. If such a patient is placed on a mechanical ventilator to take over their breathing and oxygenation, it could be very difficult to wean them off. If, on the other hand, a patient has been healthy and active until recently, and presents with respiratory failure due to extensive pneumonia, then resuscitation is more likely to be successful, and the chances of a full recovery are good. It is often the current or future quality of life that is the influential factor when assessments about resuscitation are being made by clinicians and families or carers on behalf of a patient.
A successful resuscitation can be evident within minutes, but it may not be evident for perhaps thirty minutes or more that resuscitation has been unsuccessful; basic and advanced life-support measures can maintain the breathing and circulation for this length of time and longer. Decisions about when to stop resuscitation attempts are usually made by an experienced doctor when there has been no response, and there is no treatable or reversible cause of the initial collapse. As previously observed, resuscitation should be continued for longer than usual in specific circumstances, such as in the case of children or where the collapse has been caused by electrocution, drowning, hypothermia, poisoning, or anaphylactic shock.
Advanced Decisions
Advanced Decisions, advanced directives, or ‘living wills’ can be made to specify treatment that a person might or might not want in the future. There are three legal requirements for Advanced Decisions to be honoured – existence, validity and applicability – and these have been set out for England and Wales in the Mental Capacity Act (2005).
For an Advanced Decision to be considered existent, it must be put down in writing, and be signed by the patient and a witness. For it to be valid, the Advanced Decision must not have been withdrawn or overridden by a subsequent Lasting Power of Attorney, and the patient must not have acted in a way that is clearly inconsistent with the Advanced Decision. To be applicable, the person must have had the mental capacity to make the decision about the proposed treatment at the time of writing. The Advanced Decision will not be applicable to treatments or circumstances that are not specified in the document. If there is any doubt or dispute about whether a particular advanced decision meets all the requirements, action may be taken to prevent the death or serious deterioration of the patient, whilst the dispute is referred to legal authorities. It is always very difficult to anticipate every possible scenario with regard to your health and healthcare, and therefore advanced decisions can be very limited in scope, especially when a patient presents with a new illness or condition.
Should relatives witness resuscitation?
Parents will almost always ask to be present when their child is being resuscitated. Historically, as with most medical procedures, relatives have been kept outside when cardio-pulmonary resuscitation is being performed. However, there are differing views between the public and healthcare professionals and the Resuscitation Council has published a useful document on their website about this issue.*
From the relatives’ and partners’ point of view, being present may help them come to terms with the serious illness or death of a loved one, especially when they can see that everything medically appropriate has been done. The disadvantage is that the reality of resuscitation may prove distressing, particularly if it is traumatic or if they are uninformed. Furthermore, they may physically or emotionally hinder the staff involved in the resuscitation attempt. However, it seems likely that for many relatives it is more distressing to be separated from their family member during these critical moments than to witness them. From the patient’s point of view, most would probably want to have their family present but it would be unusual for the patient to have expressed an advanced directive stipulating the inclusion of specific relatives, partners, carers or friends. For the clinical staff undertaking resuscitation, the presence of relatives could increase stress, affect decision-making, and affect the performance of the staff involved. On the other hand, verbal or physical interference by a relative could be prevented by close supervision and restriction of numbers.
Progressives believe that relatives or partners should be given the opportunity to be with their loved ones at this time, and proper provision must be made for those who indicate that they wish to stay. If resuscitation is to be witnessed by relatives, partners or carers, it is essential that they be supported throughout by appropriately trained clinical staff, and that the resuscitation team leader is prepared for and aware of their presence. Every hospital should have a written policy about the procedure to be followed when relatives, partners or carers request to be present during cardiopulmonary resuscitation and this would normally be the responsibility of the local Resuscitation Committee.
*
Summary and conclusions
Modern resuscitation methods and techniques date from the many major advances in research and development of medical practice in the 1950s and 1960s. Changes since then have mainly resulted in improvements in existing procedures, rather than in the development of new medical treatments; consequently, improvements in the outcome of cardio-pulmonary resuscitation have been relatively small. The introduction of cardio-pulmonary resuscitation in the 1960s, as with many new drugs or medical procedures, resulted in initial scepticism, followed by enthusiasm, leading to over-enthusiasm and over-use, until a more precisely defined usage becomes established. With the development of procedures, medical practice has run ahead of many of the moral and ethical issues involved in resuscitation decisions. Most of these issues, such as the applicability of Do Not Attempt Resuscitation orders and Advanced Decisions, are now being reassessed so that they come into line with current medical practice.
In general, the success rates of cardio-pulmonary resuscitation remain disappointingly low, especially in out-of-hospital resuscitation, and it does not seem likely that development
s in the near future will substantially help to improve the situation. In my view, the most helpful development would be for clinicians to be able to define in advance which people and which conditions are most likely to have a successful outcome, and which will not; there is an obvious need to be more selective about for whom, when and where we undertake cardio-pulmonary resuscitation although this is clearly much easier to do for patients in hospital.
Sudden collapse and death are in fact very rare in healthy people, and are probably becoming even rarer in countries that have falling mortality rates from heart disease. The greatest challenge is to understand when there is likely to be little or no benefit from cardiopulmonary resuscitation, and to identify more systematically those people in advance. By doing this, death could be managed in a better and more humane way – which is the whole point of this book.
In the end, doctors cannot cheat death; we can only delay it.
APPENDIX II
THE PARAMEDIC’S TALE
By Louise Massen, Clinical Team Leader, Thameside Ambulance Station, South East Coast Ambulance Service (SECAMB)
I joined Kent Ambulance Service on the i April 1993.I am second-generation ambulance service and absolutely love my job with a passion! There is nothing else I ever want to do.
We received a three-month residential training course, which was run by a specialist ambulance training college. The course encompassed emergency driving, manual handling, and the specialist ambulance aid skills required to use the equipment we need to treat a whole host of medical, traumatic and obstetric calls.
I graduated in July 1993 and was posted to Dartford Ambulance Station of North Kent. I was proud to work at the station where my father had worked for twenty years. In his day, the ambulance equipment consisted of a basic stretcher, some oxygen, a few bandages and wooden splints, and lots of blankets. I was trained in manual cardiac defibrillation, could take a blood pressure, and use a whole host of splinting and moving equipment to handle the high-speed trauma that we were increasingly being called to deal with.
In the Midst of Life Page 36