Chapter 16. Making decisions about CPR

Key Objectives of Decision-Making About CPR

Understand when CPR should or should not be attempted – CPR is an emergency procedure, but it is not always appropriate or effective.
Recognise ethical and legal principles – Decisions must be based on beneficence, non-maleficence, justice, and autonomy.
Improve communication – Effective discussions ensure patient preferences are respected.
Know when to stop CPR – Continuing futile resuscitation may cause harm and distress.
Record and document decisions clearly – Ensures continuity of care and compliance with legal frameworks.

 Ethical Principles in CPR Decision-Making

Decision-making in CPR is guided by four core medical ethics principles:

 Autonomy – Patients have the right to make their own decisions. A mentally competent individual can refuse CPR, even if it is life-saving.

 Beneficence – Healthcare providers must act in the best interests of the patient. If CPR is unlikely to provide meaningful survival, it may not be appropriate.

 Non-Maleficence – CPR should not be performed if it will cause unnecessary suffering without benefit.

 Justice – CPR decisions should be fair and non-discriminatory, ensuring access to care based on need rather than age, disability, or other factors.

 Discussing CPR with Patients and Families

✔ Shared Decision-Making – Healthcare professionals should engage in discussions early, rather than in an emergency.
✔ Explore the patient’s values – Discussions should focus on goals of care, not just CPR as an isolated decision.
✔ Advance Care Planning (ACP) – CPR decisions should be part of broader treatment plans, including ICU care, ventilation, and hospital admission.
✔ Respect patient preferences – Patients should not feel pressured but must be given the opportunity to make informed decisions.
✔ When not to discuss CPR – If discussing CPR is likely to cause significant distress, it may be avoided, but this decision must be documented.

 Tip: Some patients may change their decisions over time, so ongoing discussions are essential.

 Legal Aspects of CPR Decisions

 Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Orders

• Legally recognised but must be clearly documented and accessible.
• Does not mean withholding other treatments (e.g., pain relief, antibiotics, oxygen therapy).
• Can be overridden if the clinical situation differs from when it was originally made.

 Advance Decision to Refuse Treatment (ADRT)

• A legally binding document in the UK.
• Must be signed, witnessed, and explicitly state refusal of CPR.
• Must be applicable to the current medical situation.

 Mental Capacity Act (2005) and Decision-Making for Incapacitated Patients

• If a patient lacks capacity, decisions must be made in their best interests.
• Legal proxies (e.g., Power of Attorney, Court-Appointed Deputy) should be consulted.
• If no proxy exists, an Independent Mental Capacity Advocate (IMCA) may be involved.

 What if there is disagreement? – If there is a dispute between the healthcare team and the family, a second opinion should be sought. In rare cases, legal action may be required.

 When to Withhold or Withdraw CPR

✔ When CPR will not restart the heart and breathing – If CPR has no realistic chance of restoring life, it should not be attempted.
✔ If a valid DNACPR or ADRT exists – These must be respected unless the circumstances of arrest differ.
✔ When CPR will cause significant harm – If CPR would result in severe neurological damage, pain, or prolonged suffering, it may be inappropriate.

 Stopping CPR: When is it Appropriate?

 CPR should be stopped if:

 The patient achieves Return of Spontaneous Circulation (ROSC).
 The patient has a valid DNACPR order.
 The resuscitation effort is clearly futile (e.g., asystole for >20 minutes without reversible cause).
 Continuing CPR would cause more harm than benefit.

 Special Considerations: In cases like hypothermia, drug overdose, or electrocution, CPR should be continued for longer before making a decision to stop.

Documenting CPR Decisions

✔ Clearly record DNACPR, ADRT, or CPR recommendations in patient records.
✔ Ensure paper and electronic records are accessible to all healthcare providers.
✔ Use standardised documentation systems, such as the ReSPECT form, to ensure clarity across healthcare settings.

 Special Considerations

 CPR in Terminally Ill Patients

• CPR is often inappropriate in end-of-life care but must be individualised.
• Palliative care should be prioritised over aggressive resuscitation efforts.
• Implantable Cardioverter-Defibrillators (ICDs) should be deactivated if shocks would cause distress.

 Ethical Challenges in Decision-Making

• Avoid age-based discrimination – Age alone should not determine eligibility for CPR.
• Avoid blanket policies – Each decision should be individualised and evidence-based.

 Key Takeaways from Chapter 16

✔ CPR should not be attempted if it is futile or causes more harm than benefit.
✔ Early discussions and shared decision-making improve patient-centred care.
✔ DNACPR and ADRT orders must be documented and respected.
✔ Legal frameworks (Mental Capacity Act, ADRT, IMCA) guide decision-making for incapacitated patients.
✔ Communication is key – Healthcare teams must ensure that patients and families understand their options.