Decision about Cardiopulmonary Resuscitation (CPR)

This leaflet is about Cardio Pulmonary Resuscitation (CPR) and how decisions are made about it. This leaflet may not answer all your questions, so please talk to a member of the healthcare team looking after you if there is anything you do not understand, or if you would like more information.

What is CPR?

CPR is a treatment that is used to try to restart someone’s heart and breathing, when one or both of these has stopped. When the heart stops this is called a cardiac arrest, and when the breathing stops it is a respiratory arrest. If one stops, the other usually stops soon afterwards (cardiorespiratory arrest).

CPR includes:

• Repeatedly pushing down very vigorously on the centre of the chest.

• Blowing air or oxygen into the lungs, using either a mask over the nose and mouth, or a tube inserted into the throat or windpipe.

• At times using electric shocks to try to restart normal heartbeats.

What is the chance of CPR restarting my heart and breathing?

There is no simple answer to this, because everybody is different. The chance of CPR restarting your heart and breathing will depend on:

• why your heart and breathing has stopped

• any illnesses or medical problems you have (or have had in the past); and

• the overall condition of your health.

Many attempts at CPR do not restart the person’s heart and breathing, despite the best efforts of everyone involved. For example, when CPR is attempted in hospital, on average about two out of 10 patients survive to leave hospital. In places other than a hospital, the chances of survival are usually even lower. For some people the chance of survival will be much better than this and for others there will be no chance of benefit from CPR.

If you want more information, your healthcare team can usually explain more clearly what the likelihood of CPR working for you would be if your heart or breathing were to stop.

Is CPR tried on everybody whose heart and breathing stop?

No. It is important that CPR is not tried on everybody whose heart and breathing stop. For example, when someone is coming to the end of their life as a result of an advanced irreversible illness, and the heart and breathing stop as part of the natural process of dying, CPR will not prevent their death.

If CPR does restart the heart and breathing in these circumstances it can leave a dying person with more distress or worse health in the last hours or days of their life. For others, receiving CPR would deprive them of dignity during the very last moments of their life. For these reasons many people choose not to receive CPR when they know that they are coming close to the end of their life.

The decision not to attempt CPR is often called a Do Not Attempt CPR or DNACPR decision. Many healthcare teams will try to discuss with individual people their wishes about CPR and to record when CPR would still be wanted, as well as when it is not wanted or would not work.

Do people make a full recovery after CPR?

Although people do make a full recovery, some recover but still have poor health, and some people will be left in worse health after resuscitation from cardiorespiratory arrest. The likelihood of full recovery depends largely on:

• why the heart and breathing has stopped

• the overall condition of a person’s health; and

• how quickly CPR is started.

Those who are resuscitated by CPR are often still very unwell and need more treatment, usually in a Critical Care Unit or sometimes a Cardiac Care Unit. In some cases a person may be left with permanent brain damage or in a coma.

CPR can cause unwanted effects such as bruising, broken ribs, and (infrequently) damage to internal organs such as the lungs or liver. When there is a real chance that CPR could bring a person back to a length and quality of life that they would want, the risk of these unwanted effects is not usually enough for them to decide that they do not want CPR.

Will I be asked whether I want CPR?

This will depend on your circumstances.

• If your healthcare team think CPR would not be of benefit to you / help your recovery, they will ask if they can discuss CPR with you. Where no decision has been made in advance about whether or not CPR should be performed, it will be assumed that CPR should be attempted if cardiorespiratory arrest occurs unexpectedly. If that is not what you want, it is important to discuss your wishes with your healthcare team.

• If there is a chance your heart and breathing will stop and that CPR might be successful, your views on CPR, your medical condition, and the likely outcome of trying CPR are all very important in deciding whether CPR is the right choice for you. The health professionals looking after you will want to know what you think and make a shared decision with you.

• If CPR will not prevent your death should your heart and breathing stop, your healthcare team will make a decision not to attempt CPR. They will explain to you the decision and the reasons for it, unless they believe that telling you will cause you physical or psychological harm.

If you wish, your family or close friends can be involved in these discussions. If you disagree with a decision about CPR, you can request a second opinion.

What will happen if no decision has been made?

In an emergency, when someone collapses and their heart and breathing stop without warning, health professionals will try to restart the heart and breathing if:

• there is a chance that CPR will work, and

• the person is not known to have decided against having CPR.

What if I do not want to discuss CPR?

You do not have to talk about CPR if you do not want to, or you can ask to delay the discussion until you are ready for it.

In these situations, the health professional in charge of your care will have to make a decision in your best interests about what to do if your heart or breathing stops, taking into account your general views and wishes.

Does it matter how old I am or that I have a disability?

No. What is important is:

• your views and wishes

• your state of health; and

• the likelihood of the healthcare team being able to achieve what you want.

What if I am unable to take part in a decision about CPR?

If you cannot take part in making a decision about CPR or about other types of treatment, because you are too unwell to understand information, to make a considered choice, or to communicate your wishes, these decisions will be made in your best interests by the health professional in charge of your care.

In England and Wales

• You can plan ahead for this situation by choosing somebody who you want to be involved in future decisions, if you are unable to take part. You do this by arranging to give them a Lasting Power of Attorney (LPA) for your health and welfare.

• The Court of Protection may also appoint a Deputy with similar powers.

• If like many people, you do not have a LPA or Deputy, the health professional in charge of your care will make a decision about what is best for you, taking into account your previously expressed wishes. They will ask your family or close friends for information about these. If you have no family or friends to ask, an Independent Mental Capacity Advocate may be asked to help.

More information on how healthcare decisions are made in England and Wales when people are unable to take part in decisions, can be found under Mental Capacity at www.nhs.uk.

Can my family decide for me?

Your family and friends are not allowed to decide for you (unless they have been appointed as your legal attorney, deputy, or guardian). Whenever possible, the healthcare team looking after you will ask them about your known or likely wishes.

If there are people who you do or do not want to be told about your condition or asked about your care and treatment, you should let your healthcare team know.

I know that I do not want anyone to try CPR on me. How can I make sure they don’t?

If you do not want CPR, you can refuse it and if they know of this refusal the healthcare team must follow your wishes. It is very important to make sure that your wishes are recorded clearly and that you make them known to your family or other carers and to your healthcare team. Healthcare professionals called to you in an emergency will need immediate access to any document recording your wishes.

You can make a living will (sometimes called an Advance Statement) to put in writing your wishes about any type of care or treatment that you would or would not want to be considered for if you are not able to decide for yourself at the time. Although not legally binding, this can be important to guide health professionals who may not know you well but are having to decide what treatment would be in your best interests.

In England and Wales, you can also make an Advance Decision to Refuse Treatment (ADRT). This must be signed by you and by a witness and is legally binding. To refuse CPR it must state that you refuse it even if your life is at risk.

If you have made an ADRT or any other type of ‘living will’, you should make sure that your healthcare team knows about it and puts a copy of it in your records. You should also make sure that people close to you know about it and where you keep it, so that they can find it easily in an emergency and show health professionals what decisions or preferences you have recorded.

If it is decided that CPR will not be attempted, what then?

This is often called a Do Not Attempt Cardiopulmonary Resuscitation or DNACPR decision. Together with the reasons for the decision, it is usually recorded on a special form that makes it easy for health professionals to recognise.

Increasingly, similar forms are used to record both a decision whether or not CPR should be attempted, and decisions made in advance about other types of care and treatment that a person may or may not want to be considered for, especially as they approach the end of their life. For example, these choices may include decisions about wanting to have treatment at home and not be admitted to hospital, or choices about wanting hospital treatment but not wanting to be considered for admission to a Critical Care Unit.

Most decisions recorded on such forms will be reconsidered if your condition changes or if you are transferred, for example from hospital to home, to a nursing home or hospice, or from one hospital ward to another. The form should travel with you, so that it is always readily available to guide any health professional if your condition worsens.

What about other treatment?

A DNACPR decision is about CPR only, you will receive all the other treatment that you need. If you have recorded a refusal of other treatments, that will also be used to guide decisions about your care if your health gets worse and you are unable to make clear choices at the time.

If it has not been suggested already, you may want to discuss this with your healthcare team. You can plan with them what other types of care and treatment you would or would not want to be considered for if your health deteriorates.

What if I want CPR to be attempted, but the healthcare professional in charge of my care says it will not work?

When a decision is made that CPR will not work because a person is dying from an advanced and irreversible condition, it will usually have been discussed and agreed among several members of the healthcare team. If you are not willing to accept the explanation and advice that they have given you, they will arrange a second opinion for you if you would like one.

It is important to remember that you are not entitled to demand treatment that is not being recommended or offered. However, health professionals will not refuse your wish for CPR if there is any real possibility of it working successfully.

If CPR might restart your heart and breathing, but is likely to leave you in very poor health, your opinion about whether these chances are worth taking is very important.

The healthcare team should listen to your opinions and anyone close to you that you want to be involved in the discussion. In most cases, health professionals and their patients agree about treatment where there has been good communication.

What if I change my mind or my situation changes?

Your healthcare team will keep the decision about CPR under review. In particular if your condition changes, if you move to a different care setting or go home, or if you want to change your mind.

Can I see what is written about me?

Yes. You can see what is written about you. You can ask the healthcare team to show you your records, and if there is anything in them that you do not understand they will explain it to you.

Who else can I talk to about this?

In addition to the healthcare team looking after you, there are other people you may want to talk to about CPR, for example:

• patient support groups

• spiritual advisers; or

• independent advocacy services.

Original wording of model leaflet produced by the Resuscitation Council (UK).