Treatments: CPR and Clinically Assisted Nutrition & Hydration
Cardiopulmonary resuscitation (CPR)
Cardiopulmonary Resuscitation, CPR, embraces all the procedures, from basic first aid to the most advanced medical interventions, that can be used to restore the breathing and circulation in someone whose heart and breathing have stopped (Resus Council, 2017). The resuscitation status should be discussed with all patients at risk and the decision whether or not to perform CPR formally recorded in the patient’s medical notes, with regular reviews of that status according to clinical progress.
Decision-making in CPR
When making a decision about whether a patient should be provided with CPR should their heart stop beating, it is important for the surgeon to remember that CPR is a treatment. As such, the decision-making guidelines provided in Section 3 (Communication), in Consent: Supported Decision Making and in Treatment and Care Towards the End of Life: Good Practice in Decision Making should be followed, taking into account whether the patient has capacity or not.
There are two important factors in particular for surgeons to take into account;
1) If a cardiorespiratory arrest is expected to occur as part of the dying process and CPR will not be successful, this treatment does not need to be offered to the patient even if they have capacity. The surgeon should offer to discuss the decision with the patient and offer a second opinion where there is disagreement. The surgeon should also offer to discuss this decision with the patient’s supporters, subject to consent of the patient with capacity or in the best interests of a patient lacking capacity.
2) In cases where CPR may be successful, the surgeon should discuss the use of CPR with the patient with capacity, or make a decision in the patient’s best interests if they lack capacity (by following the steps laid out in section B, or RCS’s Consent: Supported Decision Making).9. If the surgeon believes it may be successful but clinically inappropriate, they should discuss this view with the patient. If, after discussion, the surgeon still believes that CPR is clinically inappropriate, they are not obliged to offer the treatment but should explain to the patient options for their next steps, including a second opinion and legal advice.
Other treatments at the end of life if a DNACPR decision has been made
When a DNACPR decision has been made, the surgeon must ensure that other treatments are not withheld unless a separate decision has been made to do so. The DNACPR order applies only to CPR.
It is good practice for surgeons to review the appropriateness of other treatments such as administration of regular medication, antibiotic treatment or the appropriateness of escalation to high dependency or intensive care at this point. These decisions should be made in conjunction with the patient where they have capacity, or in line with their best interests when lacking. Where these decisions have been made, they should be well documented.
Clinically assisted nutrition and hydration
Patients, paediatric and adult, should be encouraged to take nutrition and hydration orally and assisted to do so (e.g. by spoon feeding) wherever possible, even at the end of life. Where patients are unable to take food and drink orally, patients with capacity (or their LPA, if one is appointed) should be assisted in making the decision over whether they wish to receive nutrition and hydration intravenously or enterally, for example via a nasogastric (NG) tube or a percutaneous endoscopic gastrostomy (PEG) or similar.
All the risks, burdens and benefits should be explained to the patient and the decision should be regularly reviewed. In those patients lacking capacity, where no advance decision or LPA is in place, the treating surgeon should weigh up the risks, benefits and burdens and consider what is in the best interests of the patient using the framework in section B, or in Consent: Supported Decision Making. Advance statements and advance care plans may assist the clinician in discerning the best interests of the patient.
Surgeons must consider that clinically assisted nutrition and hydration may improve the patient’s quality of life or prolong the life they have left, but may have other burdens such as discomfort or distress. These treatments should only be provided if there is overall benefit for the patient.
Please note that in the case of a patient in a persistent vegetative state for whom decisions are being made about withdrawal of nutrition or hydration, courts must be approached by the clinician responsible for the patient’s care for a ruling (In England, Wales and Northern Ireland. Seek legal advice in Scotland).
This guidance is adapted from the GMC’s Treatment and Care Towards the End of Life: Good Practice in Decision Making and Care of the Dying Adult in the Last Days of Life.