Advance care planning for the end of life

Decisions related to cardiopulmonary resuscitation (CPR) can be complicated and emotive. The procedure was initially intended for victims of sudden, unexpected cardiac or respiratory arrest and for those with good survival outcomes.1 Unfortunately, its use has increased in circumstances where no decision about resuscitation has been made and the patient experiences an arrest. When CPR is unsuccessful, it results in stress to the family, carers, and healthcare professionals, and may represent an undignified death to the patient.2

The Mental Capacity Act
The Mental Capacity Act 20053 provides guidance on how to voice patient choices at the end of life, including CPR, if it is an option. Capacity is the ability to make decisions. It includes being able to understand information, retain it for as long as is needed to weigh up the pros and cons and consequences of a decision, and to communicate that decision.

The five key principles underpinning the Mental Capacity Act (see Box 1) are not complicated, but must be considered in any healthcare decision-making. Only one decision should be considered at a time, and any result of assessing the patient's capacity stands for that one decision.

Capacity can be lost permanently, as in severe dementia, or temporarily, such as from anaesthesia or infection. If capacity is lost temporarily, the decision-making process should be delayed if at all possible, until the person regains capacity. If the person does not regain capacity and will not regain it in the foreseeable future, or if the decision cannot be delayed, it is necessary to follow the ACP process.

When assessing a patient's capacity to make a decision, there is a recommended two-stage test, consisting of two questions. The first question asks if there is an impairment of, or a disturbance in, the functioning of the patient's mind or brain. Second, is the impairment or disturbance sufficient to cause the patient to be unable to make that particular decision at the relevant time? If a resuscitation decision needs to be made, it must be decided whether it is appropriate to discuss this directly with the patient. This is the most difficult question when dealing with CPR decisions.

Should the patient always be consulted?
A mistake often made by healthcare professionals is to assume that the patient must be consulted about resuscitation and asked whether they would want it. This is not the correct approach. English law states that no treatment deemed to be futile (that is, the side-effects outweigh any benefits and it will not succeed) should be offered, and patients and their families have no right to demand futile treatments. However, the resuscitation guidelines issued by the BMA, the Resuscitation Council (UK) and the RCN4 do not make this clear. In one section, the guidelines state that if resuscitation is likely to be unsuccessful, it should not be offered, but later state that if the patient is adamant they want to be resuscitated, the decision must be upheld. If an arrest subsequently occurs, the decision about resuscitation should be reviewed.

This seems to suggest that when the decision is reviewed, resuscitation would not be carried out, but this contradicts the concepts of truth telling and the patient/professional relationship. A surgical operation would not be offered if it would be futile. The same principle should apply for resuscitation.

The guidelines would be more straightforward if they followed a framework proposed in 2005,5 which states that if resuscitation is futile, it should not be offered. The National Council for Palliative Care states: 'There is no ethical obligation to discuss CPR with the majority of palliative care patients for whom such treatment, following assessment, is judged futile.'6 However, good practice should ensure there is some discussion of the aims of treatment and care, rather than no discussion.

Experience from involvement in such discussions suggests that the most effective approach to maintain trust would be to use simple phrases, such as 'nothing heroic will be done' and 'we will keep you as comfortable as we can' and to reassure the patient that preferred priorities will be followed if possible.

If there is even a small chance of successful resuscitation, this should be discussed with the patient if they have capacity. However, statistics on resuscitation success are inconsistent because of the variety of diagnoses and situations involved, and these facts also need to be taken into account.

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