Reducing futile attempts at resuscitation.

A recent review in the BMJ has drawn attention to major concerns about ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) forms.1 One of these concerns is with the distressing number of deaths that are surrounded by futile attempts at cardio-pulmonary resuscitation (CPR). Such attempts occur for a number of reasons. Some patients with terminal illnesses, or who are elderly and frail, do not have a form, perhaps because their doctors were too busy or never got round to raising the issue. Other patients may have deteriorated very soon after admission, or more quickly than anyone expected, so that no-one had a chance to discuss their wishes with them in advance. A few patients may have refused consent to having DNACPR on their records because of their beliefs, in spite of having diseases likely to lead to death. In all these circumstances, doctors who are called at the time of death will typically feel they have no authority to withhold CPR, or they fear the legal risks of doing so – in spite of knowing that what they are doing is pointless. Their fear is understandable. In the UK, the guidance from the Resuscitation Council states that should be an initial presumption in favour of CPR2 and regulators continue to impose sanctions on clinicians who decided not to resuscitate patients who had been dead for some time3 There do not appear to be any studies of how often such attempts take place, but narrative accounts of them are common.4 5 The injuries that patients sustain during such attempts include broken ribs, tracheal damage from intubation, and extensive bruising – along with a profound loss of personal dignity. Although patients in these circumstances are unlikely to be conscious of these effects, one physician has suggested that futile CPR may be tantamount to assault and might constitute torture under the European Convention on Human Rights6 Whether or not this is the case, families who witness these attempts, or the results of them, can be traumatised. Conversely, if families happen to be absent during a failed attempt, they may never be told of these injuries, raising an equally serious ethical concern. The effects of such failed attempts on the doctors and other staff who carry them out can also be harrowing.7 Some of the remedies for this state of affairs are clear. Every consultant should emphasise the importance of DNACPR forms and encourage teams to make them a priority. Educators can train junior doctors about how to hold more candid conversations with patients and families so they make more informed decisions. Hospitals should monitor the frequency of failed attempts at resuscitation and review these to see how many could have been avoided. Beyond these practical changes, however, there is clearly a need for an alteration in mind-set about the nature of resuscitation and of death itself.