Analysis

What nurses need to know if they decide not to attempt CPR

If healthcare professionals feel a resuscitation attempt is inappropriate they must be ready to defend this decision if no DNACPR order is in place
Picture shows medic writing on clipboard. If a resuscitation attempt is inappropriate and no DNACPR order is in place, you must be ready to defend your decision.

If healthcare professionals feel a resuscitation attempt is inappropriate they must be ready to defend this decision if no DNACPR order is in place

  • Clear documentation on decisions is vital in the event of fitness to practise hearings
  • If death is imminent a decision not to start CPR should be supported, guidance says
  • Expert advises nurses to be ready to challenge employers over blanket CPR policies

Nurses need to be able to defend themselves if they decide not to administer cardiopulmonary resuscitation (CPR) on a patient in cases where there is no do not attempt CPR (DNACPR) order in place, experts say.

They need clear documentation of their actions in case they face disciplinary or fitness to practise (FtP) proceedings.

In a recent high-profile FtP case a care home

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If healthcare professionals feel a resuscitation attempt is inappropriate they must be ready to defend this decision if no DNACPR order is in place

  • Clear documentation on decisions is vital in the event of fitness to practise hearings
  • If death is imminent a decision not to start CPR should be supported, guidance says
  • Expert advises nurses to be ready to challenge employers over blanket CPR policies

Clear and full documentation is vital. Picture: Alamy

Nurses need to be able to defend themselves if they decide not to administer cardiopulmonary resuscitation (CPR) on a patient in cases where there is no ‘do not attempt CPR’ (DNACPR) order in place, experts say.

They need clear documentation of their actions in case they face disciplinary or fitness to practise (FtP) proceedings.

In a recent high-profile FtP case a care home nurse was suspended from the Nursing and Midwifery Council (NMC) register after failing to attempt CPR on an 89-year-old woman who had stopped breathing.

About 8%

survival rate for resuscitation attempts in out-of-hospital cardiac arrests in UK
(National Institute for Health Research 2017)

RCN is among those critical of blanket policies

The nurse, Nahid Nasiri, was aware that no DNACPR notice was in place and the care home had a blanket policy that CPR should be undertaken in such a situation.

However, joint national guidance from the British Medical Association, the Resuscitation Council (UK) and the RCN is critical of such blanket policies, saying CPR decisions must be made based on careful assessment of each individual’s situation.

What should care home nurses do if they are faced with similar blanket policies in their workplaces?

‘It is not a legally binding document, it is a directive, and in certain circumstances, a health professional could override a DNACPR’

Ken Spearpoint, principal lecturer in medical simulation at the University of Hertfordshire

The joint guidance says that if no explicit decision on CPR has been considered and recorded in advance, there should be an initial presumption in favour of CPR.

‘Healthcare professionals will make all reasonable efforts to resuscitate the person in the event of cardiac or respiratory arrest,’ it states.

A carefully considered decision not to start inappropriate CPR should be supported

1960s

Cardiopulmonary resuscitation becomes a treatment to restart the heart after sudden cardiac arrest

But it is not always straightforward. It says that in cases where death is imminent and unavoidable and CPR would not be successful – such as for someone in the advanced stages of a terminal illness – a 'carefully considered decision' not to start inappropriate CPR should be supported.

‘There will be cases where healthcare professionals discover patients with features of irreversible death – for example, rigor mortis,’ the guidance says.

‘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.’

‘A patient could not demand that CPR is carried out if the medical view is that CPR would be inappropriate – and relatives can’t either’

Ken Spearpoint, principal lecturer in medical simulation at the University of Hertfordshire

With this in mind, University of Hertfordshire principal lecturer in medical simulation Ken Spearpoint says nurses should feel safe to challenge their employers over ‘inappropriate blanket policies’ dictating CPR in the absence of a DNACPR order.

Picture of University of Hertfordshire principal lecturer in medical simulation Ken Spearpoint. If a resuscitation attempt is inappropriate and no DNACPR order is in place, you must be ready to defend your decision.
Ken Spearpoint

Mr Spearpoint, a former nurse consultant in resuscitation, says DNACPR orders are often misunderstood by healthcare professionals and their employers.

‘A DNACPR order is not a legal one,’ he says. ‘It is not a legally binding document, it is a directive, and in certain circumstances, a health professional could override a DNACPR.’

No obligation to give clinically inappropriate treatment

The joint guidance makes clear that healthcare professionals have no obligation to offer or deliver clinically inappropriate treatment.

Mr Spearpoint says: ‘A patient could not demand that CPR is carried out if the medical view is that CPR would be inappropriate – and relatives cannot either.

‘Where an adult lacks capacity and has no appointed advocate, the guidance states that attempts should be made to discuss best interests with those close to the patient.’

Recording decisions relating to cardiopulmonary resuscitation

Good documentation includes the following, which may be on the cardiopulmonary resuscitation decision form or in the main health record, or in some cases both:

  • The decision, date and time
  • Detailed reasons for the decision
  • Name and position of the person making and recording the decision
  • Name and position of the senior responsible clinician who should review and, if appropriate, endorse the decision at the earliest opportunity
  • Details of discussions about the decision with the patient, those close to them, or anyone with authority to make decisions on their behalf
  • Where no discussions have taken place the reasons for this
  • What information was offered to the patient and those close to them
  • Members of the healthcare team contributing to the decision
  • Details of any second opinion requested and the response
  • Details of legal advice sought
  • Formal assessment of patient capacity, where necessary
  • The identity – or absence – of an individual with legal authority to make decisions for a person lacking capacity
  • Details of families or representatives to contact in the event of death, cardiac arrest or other emergency

(Source: Resuscitation Council UK 2016)

The joint guidance says it should be made clear to those close to the patient that their role is not to take decisions on behalf of the patient, but to help the healthcare team to make an appropriate decision in the patient’s best interests.

‘Relatives and others close to the patient should be assured that their views on what the patient would want will be taken into account in decision-making but that they cannot insist on a treatment or on withholding or withdrawal of a treatment,’ it says.

30,000

cardiac arrests occur outside of hospital annually in UK

(Source: British Heart Foundation 2019)

For some nurses working in care homes, situations may arise where they may not always be fully aware of a patient’s wishes or know if there is DNACPR documentation.

If in doubt commence CPR without delay

Mr Spearpoint says: ‘A bank or agency nurse might go into work and be the only qualified nurse on duty, but it could get missed in the handover that a patient has a DNACPR in place.

‘In these cases, the nurse has a very quick clinical decision to take, based on their knowledge, skills and experience.

‘If there is any doubt whatsoever, they should commence CPR without any delay, unless in their professional opinion undertaking CPR would not be beneficial – in situations where they know that the person is at the end of life.’

‘If a patient has an irreversible disease and it is determined that CPR is not appropriate, would not work or is not wanted, performing it could cause harm and an undignified death’

Spokesperson for Resuscitation Council UK

A Resuscitation Council (UK) spokesperson says that emergency care interventions, including CPR, are sometimes not appropriate or will not work.

‘If a patient has an irreversible disease and it is determined that CPR is not appropriate, would not work or is not wanted, performing it could cause harm and an undignified death.’

She emphasised the importance of having conversations in advance among senior clinicians, patients and families for a decision to be carefully and appropriately made.

‘These decisions should be made in advance as part of the patient’s care planning, and clearly documented on a recognised form.’

Picture of RCN professional lead for community and end of life care Carolyn Doyle. If a resuscitation attempt is inappropriate and no DNACPR order is in place, you must be ready to defend your decision.
Carolyn Doyle

RCN professional lead for community and end of life care Carolyn Doyle says such decisions ‘give nurses a framework to work around’ and set procedures for decisions around commencing CPR.

Be clear on your decision-making

Crucially, Ms Doyle says nurses must be able to justify – and give a clear rationale – how they arrived at a decision not to commence CPR and document it, so they are able to recall it at an NMC hearing or coroner’s court.

‘As professional people with competency around the area of CPR, we need to be able to articulate how we work,’ she says. ‘Be clear on your decision-making, that is the crux of the matter.’

On a similar note, Mr Spearpoint urges nurses to have trade union and legal representation and to attend any FtP hearing should they be referred to the regulator. ‘If they don’t, they place themselves in an undefendable situation.’

The RCN is in the process of updating the joint national guidance on CPR to ensure nurses understand better how to articulate their decision-making process.


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