Mike's Cheeky Blog: CPR decisions and discussions
Mike's Cheeky Blog: CPR decisions and discussions
I was exchanging some tweets with Professor Mark Taubert, a palliative care doctor, a few days ago. They started when a social worker tweeted to me about 'shared decision-making' (not a term that I like in healthcare). I tweeted that Mark is a good person to ask, and Mark tweeted pointing to a piece written by Dr Zoe Fritz (July 2020), and to some recent pieces which Mark had contributed to. It is reasonable for me to describe these pieces, as in essence being about decision-making for cardiopulmonary resuscitation (CPR).
The piece by Zoe is here:
https://medium.com/death-dying-and-digital/dnacpr-and-shared-understanding-46a5a8a82d4f
The piece/s writren by Mark and others can be found here:
Zoe's piece is titled 'DNACPR and shared understanding' and I liked a lot of it. In particular, 'understanding', and the sharing of undertanding, is central to the creation of 'good' end-of-life experiences. But Zoe wrote some things which I do not like. One thing Zoe wrote, is:
'... a patient can't request to be given CPR if the clinicians think that it would not be successful'
That isn't true - anybody can request anything. The situation is correctly described as 'doctors are not required to offer CPR if they are convinced CPR could not restart the heart', and a patient can only consent to a treatment which is being offered. However, in reality it is actually quite difficult for a person (the potential patient) to forbid CPR with 100% confidence that this refusal of CPR will be respected by clinicians - and myself, I consider that we need to change to 'attempt CPR if the patient wanted it':
Zoe also wrote this:
'Then the doctor understands what the patient values, and can write it down in their words'.
I am not certain who is in Zoe's view doing the writing down here - but for me, a description of THE PATIENT'S values should normally be written down BY THE PATIENT.
My other comment on Zoe's piece, is its implication that the ReSPECT Form 'is a plan'. The ReSPECT form is not a plan - it is in essence information (but the form is 'muddled' to the point of being impossible to concisely describe exactly what it is, anyway). To use an analogy, a military commander needs to understand the battlefield situation - where the enemy is, where his own forces are, who is armed with what, etc. Then, the commander comes up with a plan as to how how to fight and win the battle. The ReSPECT form, is closer to a description of which forces are where, than to the plan for how the battle will be fought.
The other piece/s, include the blog in BMJ Supportive & Palliative Care titled 'Don't judge the book by its cover - Clinicians and charities speak out about the positive role DNACPR conversations can play in providing good care' by Linda Dykes, Mark Taubert and Usha Grieve (8 March 2021). The blog linked to other pieces. The blog includes this rather more correct wording:
'... whilst in the UK, nobody can demand CPR against medical advice, many people appreciate the chance to firmly refuse CPR ...'
If we 'combine' what Zoe wrote with the phrase above, and also modify it a little, we get to what I consider to be correct in England and Wales (and probably in the UK as a whole):
'Nobody can demand CPR if the clinicians think that it would not be successful, and many people WOULD appreciate the chance to firmly refuse CPR'.
It looks, when CPR is superficially researched, as if CPR can be 'firmly refused' by means of a written Advance Decision - but in reality, even an ADRT refusing CPR is not certain to prevent attempted CPR (especially in community settings).
The piece also says:
'decisions about DNACPR are medical decisions'
No - they are not! Although it would help, if doctors would define what they mean by 'a medical decision'.
For me, it is implied by 'medical decision' that only a person with medical training can make the decision. But DNACPR decisions can be made and expressed by patients (ADRTs - and patients are not usually medically-trained), by suitably-empowered welfare attorneys (again, not usually medically-trained), and presumably by relatives and family-carers who know how to attempt CPR as first aid. See my blog in the Journal of Medical Ethics:
The thing which is 'medical' - which requires medical training - is the EXPERT OPINION that CPR could not be clinically-successful (that it would not restart the heart): DNACPR decisions arising from patient autonomy or made on MCA best-interests grounds, are clearly not 'medical decisions'. At least - clearly not 'medical decisions' in my opinion.
Professor Taubert also has a 'gripe' (to use my word, here) that the word 'decision' is not clearly defined in 'DNACPR decision', and more widely 'in an MCA context'. But that is a discussion, which I will not embark on here!