The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [384]
Sensitive advance discussion between experienced medical/nursing staff and patients regarding attempting CPR should be encouraged but not forced. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. (Note: in England, Wales and Northern Ireland, no person is legally entitled to give consent to medical treatment on behalf of another adult.) Information about CPR needs to be realistic. Written information explaining CPR should be available for patients and those close to them to read. The BMA, in liaison with the Resuscitation Council UK, RCN and Age Concern England, has published an information leaflet that may help patients and families to discuss DNAR with medical and nursing staff (BMA et al. 2002).
Patients are entitled to refuse CPR even when there is a reasonable chance of success.
Some patients may ask that no DNAR order be made. Patients cannot demand treatment which the healthcare team judges to be inappropriate, but all efforts should be made to accommodate their wishes and preferences.
An advance DNAR order should only be made after consideration of the likely clinical outcome, the patient’s wishes and the patient’s human rights. It should be considered on an individual patient basis where:
— attempting CPR will not start the patient’s heart and breathing
— there is no benefit in restarting the patient’s heart and breathing
— the expected benefit is outweighed by the burdens (Resuscitation Council 2010b).
The overall responsibility for decisions about CPR and DNAR orders rests with the consultant in charge of the patient’s care. Issues should, however, be discussed with other members of the healthcare team, the patient and people close to the patient where appropriate.
There are exceptional cases where resuscitation discussions with a patient may be inappropriate, for example where senior members of the medical and nursing team consider that CPR would be futile and that such a discussion would cause the patient unnecessary distress and anguish. This could apply to patients in the terminal phase of their illness.
The most senior members of the medical and nursing team available should clearly document any decisions made about CPR in the patient’s medical and nursing notes. The decision should be dated and the reasons for it given. This information must be communicated to all other relevant healthcare professionals. Unless it is against the wishes of the patient, their family should also be informed.
The DNAR order should be reviewed on each admission or in light of changes in the patient’s condition (BMA et al. 2002).
Finally, it should be noted that a DNAR order applies only to CPR and should not reduce the standard of medical or nursing care.
Principles of care
Failure of the circulation for 3–4 minutes will lead to irreversible cerebral damage (Docherty and Hall 2002). BLS acts to slow down the deterioration of the brain and the heart until defibrillation and/or advanced life support (ALS) can be provided (Resuscitation Council 2010b).
Assessment
There are two stages of assessment.
An immediate assessment by the rescuer to ensure that CPR may safely proceed (i.e. checking there is no immediate danger to the rescuer from any hazard, for example electrical power supply).
Assessment by the rescuer of the likelihood of injury sustained by the patient, particularly injury to the cervical spine. Although there may be no external evidence of injury, the immediate situation may provide the necessary evidence. For example, trauma to the