‘Do not resuscitate’ discussions: Can we do better?

COVID-19 must not be used as an excuse to avoid difficult discussions about Do Not Attempt CPR decisions.

Volunteers conduct CPR training by St John Ambulance instructors during their course to administer COVID-19 vaccines at Manchester United Football Club on January 30, 2021 in Manchester, England. [Photo by Christopher Furlong/Getty Images]

Since the beginning of the COVID-19 pandemic, many have raised concerns about Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in the United Kingdom, claiming that they are being inappropriately applied to groups of people without their knowledge and proper consultation with their representatives.

CPR is a treatment that can be given when someone stops breathing or their heart stops beating. It involves interventions like chest compressions, electrical shocks to the chest and artificial ventilation. DNACPR decisions should be made in consultation with patients themselves and are put in writing by their healthcare teams, when it is determined that CPR interventions would not produce beneficial outcomes. This may, for instance, be the case when someone has a very advanced cancer, and CPR would have zero chance of success.

In response to the growing concerns about DNACPR decisions during the pandemic, the Care Quality Commission (CQC), England’s independent regulator of health and social care, conducted a special review. In its report on the matter, published in February 2021, the commission said that while it found some examples of good practice, it has also heard from people “who were not properly involved in decisions, or were unaware that such an important decision about their care had been made”.

The worrying findings of the CQC review added weight to existing concerns and triggered an important discussion about DNACPR decisions and how they should be handled – both during pandemics and normal times.

Most people, who have only seen CPR attempts in movies and TV series, may believe the treatment’s success rates to be reassuringly high, and side effects minimal. Thus, they might take the default position that health professionals should always attempt CPR, regardless of circumstances and the patient’s overall condition.

This, however, is a misconception.

By way of an example, when an otherwise healthy marathon runner enters into sudden cardiac arrest and collapses, CPR can indeed be life saving. Giving electric shocks to the heart in such a situation can restore normal rhythms very effectively, and pumping the chest wall (and thereby the heart) to mimic the heart’s normal output can help keep the patient alive until a defibrillator arrives. Educating the public in basic first aid and CPR has undoubtedly saved many lives over the years.

But this is not the case in many other scenarios. A patient’s overall health can have a huge impact on the success of a CPR intervention. In patients with cancer that has spread, for example, success rates can be lower than two percent. In natural dying, the heart is often the organ that stops last, so chest compressions or electric shocks in such situations do not restore life at all.

This, of course, does not mean blanket policies can be put in place for different age groups and medical conditions. I have known 80 year olds who were physically fitter than some 40 year olds, whose heart rhythm was amenable to electric shock reversal, and for whom the intervention was appropriate. I have also known young people, with different health conditions, for whom the possibility of achieving a successful outcome from CPR was minimal, or zero.

Despite all this, you may still think, what do we have to lose? If there is a chance of survival, however slim, it is always worth trying.

But CPR in real life is not as straightforward and simple as it is in fictional accounts. Many CPR attempts involve broken ribs, blood on the floor, and traumatised families. The people who survive CPR can be left with significant organ damage, and even brain damage. Many only survive for a few more minutes or hours, and spend this little extra time either unconscious or in extreme agony, struggling to breathe with punctured lungs.

CPR procedures applied when a patient has little chance of survival not only causes unnecessary suffering, but also traumatises their loved ones – when CPR is being attempted, there is no room for quiet hand-holding, words of goodbye, or dignity.

The above examples of poor outcomes from CPR are the reason why Do Not Attempt CPR, or DNACPR, forms exist in healthcare settings and why they are so important. But they will never cease to be controversial, and we have to find better ways to talk about this elephant in the room.

I personally witnessed many patients with multiple underlying conditions from long-term kidney failure to metastatic cancer, still dying in agony after receiving prolonged chest compressions, electric shocks to the bare chest, and multiple other fast-paced interventions. Both the procedures and their aftermaths were harrowing and sometimes witnessed by next of kin. I often wondered whether these patients would have elected to have CPR if they knew what such interventions would really involve and their success rates. But health professionals rarely have honest and detailed prior discussions about CPR with their patients and loved ones, for multiple reasons.

Some, after learning that they have a condition that is irreversible, take the initiative and let their healthcare providers know whether they would like to opt out of any future CPR attempts or not. At times, they even go a step further and legally ensure that they won’t receive CPR (and other interventions) by filling in their own Advance Decision to Refuse Treatment (ADRT), which, if filled in properly, has more legal standing than a DNACPR form filled in by a healthcare professional.

But many others who have a life-threatening or terminal condition choose not to engage with this issue, or do not even know they should make a decision regarding future CPR. This leaves doctors, nurses, and paramedics in a dilemma: should we bring up the topic of CPR, explain its harms and benefits, or should we avoid talking about it?

While attempting CPR can be harmful for certain patients in certain scenarios, discussing the possibility of a DNACPR decision can also be damaging. Indeed, when a health professional brings up their view on the possible need for a DNACPR decision, a patient may assume that a situation necessitating CPR is imminent or that chances of survival are nil. This can at times cause the patient significant anxiety and cause lasting harm. Others may have cultural or even religious reasons for not wishing to engage or very reasonably wishing to obtain further information. Some of my Muslim patients have queried whether it is acceptable. And it is: according to Saudi Arabia’s Presidency of the Administration of Islamic Religion and Ifta, as stated in their Fatwa no. 12086, DNACPR forms are an acceptable part of practice.

So should healthcare professionals avoid this difficult but important conversation to not distress their patients? Or should they assume that the potential harm caused by a CPR intervention in the future is worse, and initiate a discussion?

Having early conversations with patients about their preferences for information and discussion can help us out of this conundrum. I, for example, use early, careful probing to decide which approach would benefit a patient the most: “There are things we might need to talk about in the future. Nothing urgent now, but are you the sort of person who finds it important to plan ahead for different scenarios?”

Looking at past legal disputes and multi-disciplinary discussions and research on the matter can also help physicians inform themselves about different opinions on the issue and decide what the best way forward for each of their patients might be.

Ensuring that patients have at their service all the resources necessary to make an informed decision is also important. Here in Wales, for example, we have the “TalkCPR” information videos that patients and their next of kin can use to educate themselves on the subject, as well as a national open-access DNACPR policy, which is updated regularly. The availability of such information removes some of the burden from healthcare professionals, and allows patients to arrive at an informed opinion on the issue before they discuss it with their clinicians.

It is also necessary to fight misinformation. Misinformation and untruths about DNACPR decisions have long been widespread on social media, and the COVID-19 pandemic only exacerbated the problem. I have seen commentary on Twitter likening DNACPR decisions to euthanasia, or claiming that once such a decision is made, all treatment is withheld from the patient. Patients with DNACPR decisions continue to receive all the necessary care, including, where appropriate chemotherapy, blood transfusions and other medications and interventions. If we do not fight misinformation, we cannot prevent the entire debate about DNACPR decisions from turning toxic and counterproductive.

There is no doubt that discussing the possibility of a DNACPR decision is distressing, just like it might be distressing for some to contemplate writing a will. But this type of distress is usually short in duration, so my patients tell me. They and their loved ones may even feel better once the daunting task has been completed and everyone involved has been briefed on the discussion’s outcome. There could still be cases where such a discussion would do more harm than good, and cause long-term unnecessary distress to the patient. In those rare situations, it can be acceptable for the clinician to assess the risk and decide whether the benefits of discussion justify that risk. They may conclude it to be too harmful to discuss. But in this age of patient choice and openness, many see even this as patronising.

The COVID-19 pandemic highlighted the difficult decisions made by healthcare professionals on a daily basis, but also made obvious the importance of strong communication for the likely success of certain medical interventions. This is why we need to urgently start talking about DNACPR decisions and educating the public about the harms and benefits of CPR in different situations. COVID-19 must not be used as an excuse to avoid difficult discussions or to implement blanket policies, without consultation with patients. Even if it has to be communicated via telephone or a video link, clinicians should uphold their duty to consult on DNACPR and offer their honest view on the likely future success of this and other procedures.

The views expressed in this article are the author’s own and do not necessarily reflect Al Jazeera’s editorial stance.