“Do Not Resuscitate”—Let’s Talk about CPR

I have noticed on ATS that many people have some very strong views on the various “Do Not Resuscitate” policies hospitals have and cases where staff have not attempted CPR. As such I think it is time to have a thread like this one, let’s talk about CPR and DNR.

To be clear, I am a nurse, I have quite a lot of experience in administering CPR in A&E (the ER if you’re a American) and other hospital settings. I have been involve in decisions about not giving CPR and going beyond CPR to a full blown resuscitation attempt that lasts hours on patients of all ages in a desperate fight to save their live. I

I think it is important to highlight early on in this thread that unless you have been trained to do so don’t try some of the techniques that will be discussed in this thread. It is also important to understand early on that every patient is different as is their care and I probably won’t be able to comment on the right and wrong specific cases.

So to start with I want to talk about the myths of CPR

The Myths.

It’s probably best to start by explaining some myths about CPR. I blame many of the misconceptions around CPR on TV shows like ER and Casualty. Any of you who will have seen TV probably know the routine, a big drama and some poor souls heart stops, rushed into hospital with paramedics providing CPR then there is some nurse shouting that the patients is “flat lined” and is “asystole” so they start CPR shock the guy and at the end of the show he is sitting up on bed eating some toast reflecting on his ordeal.

That is so far from the reality of what actually happens its laughable, CPR is not some magic touch it is a common misconception to assume that CPR “restarts the heart”, that is incredibly rare and even rarer that someone will survive such an event. People should not assume that CPR is anything like in the movies or even like what they might have once showed you on a manikin (ResusAnnie in my mind is a joke).

Do Not Resuscitate

Before we get into talking about who we do CPR in hospitals, lets first talk about the DNR policies, this is specific to my experience in the NHS in the UK so other countries will differ but on the whole everywhere has some kind of DNR policy. The decision to not resuscitate an individual is unbelievably complex it relies on medical staff liaising with the patient and the patients families.

That is actually where the problems start, with the families, people want their mum or dad to live its only natural and perfectly understandable. The problem is that families have to realise they don’t have the final say and sorry but neither does the patient, the final say is with the doctor. If a 90 year old man states that he wants CPR but he has metastatic cancer and multiple core morbidities the medical staff will over ride this decision in most cases and put in a DNR form against his wishes and possibly also the families. To many of you that might seem shocking but a more in-depth understanding of the system will show you otherwise.

At times the decision to attempt CPR is made in a split second, you literally have seconds to decide if CPR is appropriate or if it is not. What deems if it is appropriate or not is based on a number of factors primarily the patient inform of you but also what you know about the patient if you have a 46 year old mother of 3 who is fit and health who you find collapsed in a supermarket yes CPR is appropriate. If you have the same 46 year old mother of three who has end stage motor-neurons disease who has been in and out of ICU for years whose heart stops then it’s not so appropriate. Each case is different.

In many cases the job of nurses is to provide palliative care, we have specialist palliative care nurses who job it is to care for patients who are approaching death. We have things like the Liverpool Care Pathway that enables us to make a individuals death as comfortable as possible. The DNR is a valuable component of palliative care many patients welcome discussions around death to help them cope with facing their own mortality. A nurses Job is not only to save a live but also to care for a person who is dying and let them die.

I personally have not done CPR on an elderly lady who did not have a DNR from in place because I deemed it to be in appropriate, the ethics committee of the hospital agreed with me. I used my clinical judgement and after quickly consulting my colleagues decided not to go ahead with CPR. Rather I held her hand and she passed away peacefully.

Sometimes however, actually lots of times, CPR is attempted.

CPR

The problem with peoples perceptions of CPR is their own ignorance, it is not some magic touch.

The aim of CPR is not to actually to restart the heart (although in rare cases it can do so), rather the aim of CPR is to maintain some level of oxygen to the cells of the body before the die until another medical intervention usually an electrical shock which might restart the heart. The problem with that however is that contrary to what your TV is telling you there are only some heart rhythms that are “Shockable rhythms” (such as a AF). When we say someone has had a Cardiac arrest and is in asystole after say a massive heart attack medical staff will have to continue CPR until they push the heart into one of these shockable rhythms. Without being hit with the defib the chances of survival are incredibly slim, almost nobody survives from a cardiac arrest with just CPR alone and after three minutes of no CPR the brain will already be hypoxic

There are lost of other things that go on we will also have to perform a rapid sequenced intubation, basically sticking a tube down someone’s throat. They will require big, and I mean big needles in their arms but if we can’t get to them because the circulation has shut down that causes other problems. The patient will be on various monitoring most importantly SPo2, something we call continuous cardiac monitoring (other places have different names) and blood pressure monitors (there can be much more than these three depending on the setting). In addition to this the will probably require some inotropic drugs such as Adrenalin or dopamine. I could probably go on about this all day but that is what is done with a very basic arrest, and doesn’t even start to talk about “reversible factors”.

To the Arm-Chair nurses.

This is a phase I have coined for individuals who accuses nurses and doctors for that matte as “murderers” for not attempting CPR. Just like it’s a bit stupid to a solider for you to say to him “well you could have shot the suicide bomber on the leg”, its also a bit stupid to say to a nurse that “well you could have done CPR on the 88 year old with chronic heart failure”. This issue that many people fail to realise is that CPR in lots of cases is not in the best interest of the patient, as nurses we seek to preserve quality of live. There is no dignity for a 88 year old who receives CPR only to live out her last days hooked up to life support only for medical staff to switch it off in the end.

Death is a inevitability of life, we can only prolong it for so long before we have to let nature take is course and accept death.

So please feel free to ask questions and discus the points I have raised but please refrain from calling me or my colleagues “murderers”.

Having my dad leaving this world last year and while i would love to still have him around the fact his system was worn out fighting infections so when they finally put him on the LCP it was only a few hours but in some ways it was better as we got a final point after years of struggle due to previous medical work on him he was unable to to be resuscitated so there was not much hope for him but he survived a good few years but the last year was no fun due to his immune system failing so when he got put on the LCP we had time to gather friends and family and say good bye properly

Click here for more information.

reply to post by beckybecky


There is no such thing as a pathway to death, I bet you have never ever actually seen a LCP let alone used one

I don’t get any bonus if a patient dies

I don’t have time to sit around the nurses’ station chatting

I don’t think you will be saying we should have a 50% pay cut when you end up on a ward

And I already do more than enough paper work.

You clearly know nothing about nursing please stop with your ignorance.

reply to post by beckybecky


Troll and just lies.
Tell you what you work in a old folks home and see them constantly in pain and asking you everyday to let them die but we do not let them die even when they refuse to eat or drink we send them to the hospital and they rehydrate them to start the cycle again.
We have to bring in living wills to let people decide when they can die, we treat animals better than humans we put them down.
At least study the thing.

www.liv.ac.uk...

reply to post by OtherSideOfTheCoin


Great Thread. Coincidentally, I just had a rare conversation with someone about this today.
Your timing is superb.

The legal issues are of concern when DNR has been legally requested/documented,
as 911 would order you to start CPR
immediately.

Thanks for your Sharing your experiences and knowledge.
S&F !!!

Just to point out Nurses are amazing people they deal with stuff I nor many here could not.
Instead of listening to armchair nurses why not listen to the people who do the job eh~?

I am trained by the Red Cross for CPR and other emergency issues.

I wouldnt care about any 'policy' or 'guideline'.

I would perform as needed until help arrived, without hesitation.

And I would hope for the same if any of my family or friends needed help.

Right here is the problem::::

"The problem is that families have to realise they don’t have the final say and sorry but neither does the patient, the final say is with the doctor. If a 90 year old man states that he wants CPR but he has metastatic cancer and multiple core morbidities the medical staff will over ride this decision in most cases and put in a DNR form against his wishes and possibly also the families."

That is a good case of murder. When you take someones life against their will it is MURDER. Simple.easy to understand, even a 5 year old can understand that. It doesn't matter what justifications you bring forth. Simple.If you take someones life against their will it is murder.

reply to post by smirkley


That is fine but what you’re saying is as an individual preforming first aid something that I would say everyone should learn and put into practice when it is needed. By all means as a first aider if you find someone, anyone on the street who needs CPR you give them CPR.

CPR in a first aid situation however is a entirely different situation to CPR in a emergency resuscitation situation in a hospital. We do things totally different, we don’t even go at the same ratio of compressions to rescue breaths that they teach first aiders depending on the situation.

reply to post by ohioriver


It's not taking a life, it's withholding treatment. Not quite the same, although I agree that paragraph gave me pause, too.

Just seems a trifle slippery-slope to me.

ETA: Great thread, OP. S&F

I know that here, in the state I am in, a Doctor CAN NOT under any circumstances override a DNR - OR - Put one on someone without their consent. If a Doctor, put a DNR on someone, over the patients objections, and that patient died when something could have been done, Mr or Ms Doctor would be sitting in jail. Here a DNR is the PATIENTS choice, not the Doctors.

reply to post by ohioriver


You see that is an oversimplification.

Let’s suppose we have a 73 year old man with full blown metastatic cancer and other core morbidities (say dementia and diabetes) he says he wants CPR and the family also say they want CPR.

CPR for a patient like that is not going to be successful because as much as he might want it the best possible outcome is for him to end up on life support which will eventually have to be turned off, we cannot keep a person indefinitely on life support. As such after a couple of weeks his machine will have to be turned off and he will die because the cancer at that point has won and he is now dead.

In that instance CPR is not the appropriate course of action and while the family and patient might not see it that way the more objective medical staff will see it that way.

Essentially medical staff have the right to withhold treatment if they can justify it, which in the case above they most certainly could.

That is the key difference, withholding treatment is not murder, by not giving CPR we are not taking another’s life or doing anything that will kill them. Rather what we are doing is withholding a treatment that is not appropriate.

My father-in-law had a DNR and passed recently.
The discussion we had with him way in advance was quality of life.
In his words,"when it's my time to go,let me go".

He fought for 6 years dealing with cancer,chemo,radiation,the whole bit.He would get better,then the cancer would come back.He was only 60 years old.

If there is a good chance of living a life of quality,go ahead and and save me.
But if not,let me go.

reply to post by OtherSideOfTheCoin


This.


All day every day.

reply to post by kdog1982


Thank you for sharing your story, I am sorry for your loss.

I think perhaps I should have been clearer in the OP that the patients views on DNR are most important followed by the family and lastly the medical staff. It is only when the family and patient are being very unrealistic about the chances of survival that medical staff will override a decision.

Originally posted by alien
reply to post by OtherSideOfTheCoin

 

This.


All day every day.

yup for 12 hours

oh the joys of cleaning up poo for 12 hours a day.....

still love my job though, to some thats probalby very strange...

reply to post by OtherSideOfTheCoin


Lol and when we have to classify the poo with the Bristol poo Chart lol.
en.wikipedia.org...

Eeeee the joys of working in care.
Seeing I have to look at it every working day here it is.



Today I passed a number 3 funny though I always look now

reply to post by OtherSideOfTheCoin


Heh. Thats one of the reasons I left General Med and specialised in Mental Health...

...any poo I need to clean up now has been flung at me from someone very much living...




Like you - wouldn't trade it for anything.
Best profession you can ever get into...two decades later I still look forward to each day...

reply to post by vkey08

I know that here, in the state I am in, a Doctor CAN NOT under any circumstances override a DNR - OR - Put one on someone without their consent. If a Doctor, put a DNR on someone, over the patients objections, and that patient died when something could have been done, Mr or Ms Doctor would be sitting in jail. Here a DNR is the PATIENTS choice, not the Doctors.

I have written this very much from the UK perspective however I really do welcome information about how it is handled in other countries so I thank you for your contribution.

I must say though I am very surprise that it is so black and white that no doctor under any circumstances can refuse CPR if that’s what the patient wants, any patient. There are some patients for who it is just plainly obvious CPR would not work for yet they still might demand it so in that situation I am curious about how long they attempt CPR and just how far they would go with the resuscitation before they gave up.

Thanks for posting.