Since the onset of the COVID-19 pandemic, many have expressed concern about the Non-Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in the UK, claiming that they are being inappropriately applied to groups of people without their knowledge and with the proper consultation of its representatives.
CPR is a treatment that can be given when someone stops breathing or their heart stops beating. It involves interventions such as chest compressions, electric shocks to the chest and artificial ventilation. DNACPR decisions should be made in consultation with the patients themselves and should be written by their healthcare teams, when it is determined that CPR interventions would not produce beneficial results. This may be the case, for example, when someone has very advanced cancer and CPR would have no chance of success.
In response to 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 subject, published in February 2021, the commission said that while it found some examples of good practice, it also listened to people “who were not properly involved in decisions or were unaware of such a decision. important about his had been taken care of ”.
The troubling findings of the CQC review added weight to existing concerns and sparked a major debate about DNACPR decisions and how they should be managed, both during pandemics and in normal times.
Most people, who have only seen CPR attempts in movies and TV series, can believe that treatment success rates are quietly high and side effects are minimal. Therefore, they could take the default position that health professionals should always attempt CPR, regardless of the circumstances and general condition of the patient.
This, however, is a misconception.
As an example, when an otherwise healthy marathon runner goes into a sudden cardiac arrest and collapses, CPR can save lives. Giving electric shocks to the heart in this situation can restore normal rhythms very effectively and pumping the chest wall (and therefore the heart) to mimic the normal output of the heart can help keep the patient alive until a defibrillator. Educating the public on 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 major impact on the success of a CPR intervention. In patients with cancer that has spread, for example, success rates may be less than two percent. By dying naturally, the heart is often the organ that stops, so chest compressions or electric shocks in these situations do not restore life.
This, of course, does not mean that general policies can be established for different age groups and medical conditions. I have known 80-year-old children who were physically fitter than about 40 years old, whose heart rate was susceptible to electric shock reversal and for whom the intervention was appropriate. I have also met young people with different health conditions for whom the chance of achieving a successful CPR result was minimal or nil.
Despite all this, you can still think: what should we lose? If there is a chance of survival, however scarce, it is always worth a try.
But real-life CPR is not as simple and straightforward as it is in fictional accounts. Many CPR attempts involve broken ribs, blood on the floor, and traumatized families. People who survive CPR can have significant organ damage and even brain damage. Many only survive for a few more minutes or hours and spend this little extra time unconscious or in extreme agony, struggling to breathe with their lungs punctured.
CPR procedures applied when a patient has little chance of survival not only cause unnecessary suffering, but also traumatize their loved ones; when trying to perform CPR, there is no room for a quiet handshake, words of dismissal, or dignity.
The above examples of poor CPR outcomes are why there are forms of not attempting CPR or DNACPR in healthcare settings and why they are so important. But they will never cease to be controversial and we need to find better ways to talk about this elephant in the room.
Personally, I have witnessed many patients with multiple underlying conditions, from long-term kidney failure to metastatic cancer, who are still dying in agony after receiving prolonged chest compressions, electric shocks to the bare chest, and various fast-paced interventions. Both the procedures and their consequences were distressing and sometimes witnessed by closer relatives. I often wondered if these patients would have chosen to do CPR if they knew what these interventions and their success rates would really involve. 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 an irreversible condition, take the initiative and inform their healthcare providers whether they would like to opt for any future CPR attempts or not. Sometimes they even go one step further and legally ensure that they will not receive CPR (and other interventions) by filling out their own prior denial of treatment (ADRT) decision, which, if properly completed, has more legal capacity. than a DNACPR form completed by a healthcare professional.
But many others who have a life-threatening or terminal condition decide not to get involved in this problem or don’t even know they should make a decision about future CPR. This leaves doctors, nurses and paramedics in a dilemma: should we raise the issue of CPR, explain its harms and benefits, or should we avoid talking about it?
While attempting CPR may be detrimental to certain patients in certain scenarios, discussing the possibility of a DNACPR decision may also be detrimental. In fact, when a healthcare professional presents their opinion on the possible need for a DNACPR decision, a patient may assume that a situation that requires CPR is imminent or that the chances of survival are nil. Sometimes this can cause significant anxiety to the patient and cause lasting damage. Others may have cultural or even religious reasons why they do not want to participate or want to obtain information more reasonably. Some of my Muslim patients have asked if it is acceptable. And it is: according to the Presidency of Saudi Arabia of the Administration of Islamic Religion and Ifta, as stated in its Fatwa no. 12086, DNACPR forms are an acceptable part of the practice.
So should healthcare professionals avoid this difficult but important conversation so as not to distress their patients? Or should they assume that the potential harm caused by a CPR intervention in the future is worse and start a debate?
Having early conversations with patients about their information and discussion preferences can help us get out of this puzzle. I, for example, do an early and careful survey to decide which approach would benefit a patient the most: “There are things we might have to talk about in the future. Now there is nothing urgent, however, are you the type of person who thinks it is important to plan different scenarios in advance? ”
Analyzing past legal disputes and multidisciplinary discussions and research on the issue can also help physicians learn about different opinions on the issue and decide what may be the best way to proceed for each of their patients.
It is also important to ensure that patients have all the resources they need to make an informed decision. In Wales, for example, we have “TalkCPR” information videos that patients and their relatives can use to educate themselves on the subject, as well as a national DNACPR open access policy, which is regularly updated. . The availability of this information removes part of the burden on healthcare professionals and allows patients to come to an informed opinion on the subject before discussing it with their doctors.
It is also necessary to combat misinformation. Misinformation and lies about DNACPR decisions have been widespread on social media, and the COVID-19 pandemic only exacerbated the problem. I have seen comments on Twitter comparing DNACPR decisions with euthanasia, or stating that once that decision is made, all treatment is withheld from the patient. Patients with DNACPR decisions continue to receive all necessary care, including, where appropriate, chemotherapy, blood transfusions, and other medications and interventions. If we do not fight misinformation, we cannot prevent the whole debate on DNACPR decisions from becoming toxic and counterproductive.
There is no doubt that discussing the possibility of a DNACPR decision is distressing, just as it could be distressing for some to consider drafting a will. But this kind of distress usually lasts a short time, so my patients tell me. They and their loved ones may even feel better once the daunting task is completed and all participants have been informed of the outcome of the discussion. There could still be cases where this discussion would do more harm than good and cause unnecessary long-term distress to the patient. In these rare situations, it may be acceptable for the physician to assess the risk and decide whether the benefits of the discussion justify that risk. They may conclude that it is too harmful to discuss. But in this time of choice and patient openness, many even see it as condescending.
The COVID-19 pandemic highlighted the difficult decisions that health professionals make on a daily basis, but also highlighted the importance of strong communication for the likely success of certain medical interventions. That is why we urgently need to start talking about DNACPR decisions and educating the public about the harms and benefits of CPR in different situations. COVID-19 should not be used as an excuse to avoid difficult discussions or to implement general policies, without consulting with patients. Even if it is to be communicated by telephone or a video link, physicians should fulfill their duty to consult DNACPR and offer their honest insight into the likely future success of this and other procedures.
The views expressed in this article are those of the author and do not necessarily reflect the editorial stance of Al Jazeera.