This post is about scenario planning and CPR. The new RESPECT resource purposely, and quite rightly, considers CPR in the context of other advance care planning decisions. But even with RESPECT, I dont think worries and discussions about CPR and DNACPR orders are going away anytime soon. I’ve already suggested that scenario planning could help here.
I want to start by making it clear that CPR can be a very good thing.
It’s definitely a very bad thing that, in the UK, only 8% of people who collapse not-in-a-hospital survive CPR.
Better ‘bystander’ CPR could and would improve this overall figure. My posting on ‘Learn CPR from YouTube’ is for the pupils of a supplementary school in East London, and in August I will be speaking about CPR on a satellite channel aimed at the Bengali community.
Sadly, though, some people are never going to benefit from even the best CPR.
The Resuscitation Council is clear that, when “a person is dying—for example, from organ failure, frailty, or advanced cancer—and his or her heart stops as a final part of a dying process, CPR will not prevent death and may do harm.”
To be more specific, “Cardiopulmonary resuscitation is futile for in-hospital cancer patients with widespread incurable disease and poor performance status.”
However, there are lots of people for whom the situation around CPR is less clear cut. These individuals might benefit from a discussion of the worst, usual and best possible scenarios.
Let’s start with the best case. We’re concerned here with people who have organ failure, frailty or cancer. So the very best case scenario, in medical terms, is that they get back to how they were before the CPR. Usually the CPR only happens because something has got much worse – so the ‘best case’ may well not be very good.
International meta-analyses have found that that survival after CPR is even lower for older patients, and for those who need help with activities of daily living.
For example, two large meta-analyses, found that survival to hospital discharge decreased especially when the patients were aged over 70., Of course, age can be a ‘marker’ for overall health or functional status, so van de Glind’s 2013 meta-analysis concluded that “older age alone does not seem to be a good criterion for denying patients CPR”.
What about the less good outcomes? There are some very bad scenarios after CPR for people with chronic diseases.
I’ve already shared one of these, with Debbie’s story. Michael Stone has described another — when paramedics make decisions about individuals they have never previously even spoke to. These stories are not actually the worst case scenario, in my view. I think surviving with one’s heart beating and significant hypoxic brain damage would be even worse.
Other people may, of course, think differently — but I think that everyone making a choice for themselves should surely know of these potential scenarios.
I also think that patients and their families might want to consider another sort of scenario altogether…
When my own father died (of cancer), no-one attempted CPR. Instead, I kissed him, told him I loved him and laid down beside him.