NMC ruling could encourage futile CPR

The NMC's decision to caution a nurse for not attempting to resuscitate an elderly nursing home resident who had no signs of life has alarmed nurses and doctors, who fear it will encourage defensive practice

What would you do if you found a patient had died in the night while under your care? Most nurses would inform their superiors and probably play a part in contacting relatives with the bad news. Their actions would be aimed at protecting the dignity of the person who had died and showing respect for them and their bereaved family.

But a recent ruling by the Nursing and Midwifery Council (NMC) suggests that a nurse who discovers someone who has died should instead initiate cardiopulmonary resuscitation (CPR), unless there is a do not attempt resuscitation (DNAR) order in place.

The NMC cautioned Jane Kendall, a nurse at a Lancashire nursing home, who was called to an elderly resident's room by a healthcare assistant. Ms Kendall told the NMC that the resident was not breathing, had no pulse or other signs of life, and was 'waxy, yellow and almost cold'.

Ms Kendall, who was first registered in the 1970s, admitted misconduct in not initiating CPR and calling for emergency assistance, and acting outside of her competence. She was placed under caution by the NMC for two years, after the panel heard that she had reflected on the event, expressed remorse and undergone retraining.

Potential distress

The ruling has concerned many healthcare professionals who feel that a resuscitation attempt on someone who is clearly dead is not only futile, but disrespectful and potentially distressing for others.

Although this was a case where death was not expected, the nursing home resident may have died some time before Ms Kendall was called.

Gordon Caldwell, a consultant physician at Western Sussex Hospital NHS Foundation Trust, says he is 'mystified' by the NMC's action. 'They don't seem to distinguish between dying and cardiac arrest,' he says. 'Reading between the lines, for the body to have been cooling, death probably occurred an hour before, at least.'

Dr Caldwell is also surprised that a society 'squeamish' about post-mortem examinations can tolerate healthcare professionals 'doing CPR on dead bodies'.

'There is a real risk this decision could make nurses more likely to start CPR against their better judgement.'

- RCN director of nursing, policy and practice Dame Donna Kinnair

Elaine Maxwell, a former executive nurse who is now associate professor at London South Bank University, says Ms Kendall's description of the body suggests rigor mortis may have started.

Best interests

Guidelines drawn up by the British Medical Association, RCN and the Resuscitation Council say 'every decision about CPR must be made on the basis of a careful assessment of each individual's situation' and 'if there is no realistic prospect of a successful outcome, CPR should not be offered or attempted'.

Crucially, the guidelines acknowlege 'there will be cases where healthcare professionals discover patients with features of irreversible death, for example, rigor mortis. In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies.'

The best practice guidelines are not mentioned in the NMC panel's written decision. 'I can't say if that nurse was right or wrong,' says Ms Maxwell. 'But what I can say is that the NMC does not seem to have used best practice guidelines.'

She adds: 'If as a trained, educated nurse you use your clinical acumen and skills to decide the patient has died, you have to act in the best interests of the patient. That does not mean jumping up and down on their chest.'

The ruling seems to imply that there is a duty to start resuscitation in the following circumstances: where a patient dies unexpectedly, where there is no DNAR order that the nurse is aware of, and where there is no traumatic injury or similar that would make such attempts futile.

While nurses would start resuscitation in such situations with a patient who has just gone into cardiac arrest or who has some signs of life, the ruling seems to suggest that CPR be performed even if the patient appears dead, and does not indicate when this obligation ends. 

Fear of repercussions

There is concern that the ruling will lead to more defensive practice, when a procedure that is not expected to help a patient is carried out because of the fear of repercussions if it is not.

RCN director of nursing, policy and practice Dame Donna Kinnair told Nursing Standard: 'There is a real risk this decision could make nurses more likely to start CPR against their better judgement. 

'There should be a presumption in favour of CPR where no explicit decision has been recorded. But this does not, and should not, preclude healthcare professionals making a carefully considered judgement as to whether CPR is appropriate. There will be cases where nurses come across a patient who shows clear signs of death, such as rigor mortis.

'In these circumstances, nurses should feel confident making an ethical decision not to start CPR if it is clearly not in a patient's best interests, supported by colleagues and senior staff.'

There is some anecdotal evidence that nurses and ambulance staff are already being asked to perform CPR in cases where they know it is pointless. In a case reported to Dr Caldwell, an NHS worker was told by ambulance control staff to initiate CPR on his grandmother, who had died peacefully at home after having dementia for many years. He refused, explaining that his grandmother was clearly dead and the body had cooled, but when ambulance staff attended they started CPR.

Care planning conversations

Ms Maxwell points out that there is potential for resources to be wasted, as emergency services will be called to cases when someone is clearly dead.

Ann Gallagher, professor of ethics at the University of Surrey, suggests that wider use of advanced care planning discussions could avoid similar cases in the future. 'Most importantly, we need to prevent this kind of situation arising in residential care again,' she says. 'It is distressing for residents, families, nurses and the emergency services to have aggressive interventions when this is not clinically indicated, is futile or is not in keeping with a resident's wishes.

'It is possible to avoid such situations by implementing advance care planning conversations with all residents and families so they are consulted about end of life decision-making.'

As Ms Kendall admitted the charges against her, it seems unlikely that the NMC's decision will be reversed.

Alison Moore is a freelance health journalist