Who should make resus decisions?

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Who should make resus decisions?

• Dr Regina Mc Quillan
• Palliative Medicine Consultant

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Guardian newspaper
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Goals of Care

• To cure sometimes, to relieve often, to
• comfort always

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An intervention may

• Cure
• Rehabilitate
• Prolong life
• Stabilize condition
• Palliate
• Fail

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Ethical Behaviour

• Good is to be done and evil avoided
• Act in the patients best interests (Medical
  Council 4.1)
• Primum non nocere
• Beneficence
• Non-maleficence
• Consider which treatment option would provide the
  best clinical outcome for the patient (Medical
  Council 34.6)

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Twentieth century

• Antibiotics
• Surgery and anaesthetic advances
• Cancer treatment
• Diabetes management etc, etc
• Create an expectation that health can be
  maintained and death deferred, but at some point,
  treatment not helpful

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Challenges in treatment decisions

• Drive to do all to prolong life
• The technological imperative
• Sanctity of life

• Appropriate recognition of impossibility of
  prolonging life, and preventing death
• Rights and responsibilities to withhold or
  withdraw treatment

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Do Not Attempt Resuscitation Order

• A form of advance directive or advance care plan

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DNAR

• Urgent need to institute treatment
• At a time when patient is unable to consent

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If there is no DNAR, presumption in favour of ACPR
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Medical Council- End of Life Care

• 22.2 There is no obligation to start or continue
  a treatment, or artificial nutrition or
  hydration, that is futile or disproportionately
  burdensome
• 22.4 You should take care to communicate
  effectively and sensitively with patients and
  their families so that they can have a clear
  understanding of what can and cannot be achieved

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Futility

• Futility is goal specific
• Physiological futility is when the proposed
  intervention cannot physiologically achieve the
  desired effect. Most objective definition
• Quantitative futility is when the proposed
  intervention is highly unlikely to achieve the
  desired effect.
• Qualitative futility is when the proposed
  intervention, if successful, will probably
  produce such a poor outcome that it is best not
  to attempt it
• Sokol, DK. BMJ 2009 338b2222

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Futile treatment as ritual

• Rituals are used to make sense of life events
• CPR may be futile, but when it fails, clearly
  defines for the family and staff the moment of
  death
• Mohammed and Peter, Nursing Ethics, 2009,16(3)
  292-302

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Attempted cardiopulmonary resuscitation

• Less than 2 success rate
• Success rate lower with increasing age,
• co-morbidities, unwitnessed arrests, out of
  hospital

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When to make decision?

• Health care transitions
• New diagnosis of fatal illness
• Deterioration in chronic illness eg
• -multiple admissions with eg COPD, CCF
• -MND needing RIG or NIV
• -nursing home admission
• -dementia with feeding problems
• -cancer progression

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Who makes the decision?

• Patient choice to refuse treatment even if life-
  prolonging
• If ACPR is not futile, consider patient
  involvement
• If ACPR is futile, should not be offered
• If patient requests ACPR which is considered
  futile, explore understanding of ACPR the
  patients wishes should be respected where
  possible. Doctors are not required to give
  treatment against their wishes.
• 
  DHRMF 2010

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Who makes the decision?

• No one has the right to make a health care
  decision for an adult.
• Decision-making is the responsibility of the
  doctor in charge, and must be in the best
  interests of the patient, in consultation with
  the multidisciplinary team and the patients
  family network
• Consultation with the family, sensitive and clear

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Family
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Family

• Whose is the family?

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Family

• Whose is the family?
• Their role is to represent what the patients
  wish may be
• Must consider the patients best interest

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Team conflict
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Team conflict

• If you keep on doing what you are doing, you will
  keep on getting what youve got

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Team conflict

• If you keep on doing what you are doing, you will
  keep on getting what youve got
• Everybody acts in the patients interest

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Team conflict

• If you keep on doing what you are doing, you will
  keep on getting what youve got
• Everybody acts in the patients interest
• How to effect change

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Communicating the decision

• To the patient, if appropriate
• To the family, for information, not decision
• In healthcare record
• In transfer documentation

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Who makes resus decisions?

• The patient can refuse
• The patient cant insist on futile treatment
• If there is doubt about the value, the doctor
  makes the decision, in the best interests of the
  patient, following consultation with the patient,
  family and MDT.

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Additional reading

• Medical Futility its Meaning and Ethical
  Implications. Schneiderman, Jecker, Jonsen.
  Annals of Internal Medicine. 1990112949-954
• Debate Extraordinary means and the sanctity of
  life. Journal of Medical Ethics. 1981 74-82
• Guide to Professional Conduct and Ethics for
  Registered Medical Practitioners 2009

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