Talking about resuscitation
Doctors are often reluctant to start conversations about resuscitation decisions. In a recent issue of the British Medical Journal (BMJ), four articles discuss decisions on “Do not attempt cardiopulmonary resuscitation” (DNACPR), to spark debate about an area of clinical practice often fraught with legal and ethical challenges.
DNACPR notices first appeared in the 1970s to prevent cardiopulmonary resuscitation that people didn’t want or that wouldn’t work. They have protected many people from harm. But when isolated from other treatment decisions they have become a problem for patients and clinicians. Inconsistencies in decision making, communication, and documentation have led to misunderstandings. Doctors are hesitant to raise DNACPR in case it distresses patients or leads to a complaint. But patients rarely start this conversation either, even though research shows that many older people are perfectly willing to talk about the limits of treatment.
A way out of this impasse is to shift the focus from the specific decision about resuscitation to plans that focus on broader emergency care preferences, of which it is but a part. One approach discussed in the BMJ is an ’emergency care plan’ that focuses on broader goals such as “do all you can to keep me alive and well” or “don’t try to keep me going if I’d lose my independence.” The approach can be begun in different care settings, including on admission to hospital or at an outpatient clinic for a patient with a life limiting condition.
Such plans are to be applauded. They will be a valuable guide to doctors and will ensure that every hospital will eventually have the same form. However, it is clear that ‘an emergency care plan is not an ‘order’ and is not legally binding.
The Mental Capacity Act (2005) does allow a person to create a legally binding Advance Decision to refuse treatment (ADRT) that covers all circumstances if s/he loses capacity. For the ADRT to be valid the treatment to be refused must be specific and the circumstances stated. To complete an ADRT requires discussions over time with empathy, ideally involving both the person and his/her family or close friend. The decisions are best made before any crisis arises.
The ADRT allows choice and control at the end of life and is invaluable for all patients with early dementia, for those with a life-limiting condition or older people who might become fragile. Motor accidents and stroke affect people of all ages and so the ADRT apply to the ‘fit & well’ as much as to the above patient groups. Furthermore, when the ADRT is interpreted in conjunction with an Advance Statement of preferences and wishes (not legally binding), then health care professionals will be aware of patients wishes, beliefs and values.
The new proposal is welcome but doesn’t’t replace the need and value of the ADRT.