Better CPR in hospitals? Don’t forget DNACPR!

A BMJ editorial suggested the “widespread non-adherence to clinical guidelines” about in-hospital cardiac arrests should promote “soul-searching”. I think something quite different is needed.

First, we already know some of the ways to increase survival. The Get With the Guidelines dataset (just published in JAMA cardiology) has shown that monitoring for interruptions in chest compressions; monthly reviews of cardiac arrests; and adequate resuscitation training can help.

Maybe all UK hospitals do all of these.

Maybe.

But what I didn’t see in any of the analyses was any consideration of the patients who have, or might benefit from, a DNACPR (Do Not Attempt CPR) order.

These patients have lower rates of survival, if they do have CPR. Increasing numbers of appropriate DNACPR orders – of course with patient and family consultation – might be one of the many reasons for the encouraging trend over time in CPR survival. But we can’t know, because patients with a DNACPR order are ignored in the CPR datasets – and in all other routine data.

For patients with a DNACPR , CPR success isn’t about survival. It’s about avoiding the “medical battleground” of CPR, and having a natural death, surrounded by loved ones.

Counting this sort of success could be a start towards having more of it.

Of course, the Emergency Care and Treatment Plan currently being consulted on by the Resuscitation Council may help move things forward. But there will still be questions to consider over DNACPR orders.

And unless something is counted, it feels like it doesn’t count.

 

Look here for more doctor-speak stuff in my BMJ Rapid Response. So far, 24 people liked my comment! I’m thrilled!

Here, here, and here are the articles that got me going.

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