“In hospitals there are all kinds of treatments we can offer a patient. In order for me to understand which ones you would benefit from, it’s really helpful for me to know what outcomes you value and which outcomes you fear.”
Dr Zoë Fritz
8 July 2020
DNACPR and shared understanding
Do not resuscitate (DNR)
Guest post
Today’s guest post comes from Dr Zoë Fritz, Consultant in Acute medicine, Wellcome Fellow in Society and Ethics, Cambridge University and University Hospitals, lead on the ReSPECT process.
First of all, why do I think this is about shared understanding rather than about shared decision making?
There are all kinds of areas where shared decision making is important: where someone is choosing which type of medicine to start or which procedure to have, or even whether they should enter into a screening programme.
Here shared decision making is great because the doctor can explain all the options that are available, what the benefits and risks are of each of them. They can then understand from the patient what’s important to them, and together they can make a shared decision.
But cardiopulmonary resuscitation (CPR) is different to that. A patient can’t request to be given CPR if the clinicians think that it would not be successful, any more than other medical treatments — say operations — can be requested.
CPR can have a good chance of working if the heart suddenly stops. But if someone is dying because their organs are failing, or because they have a cancer, or because they are just very frail, and the heart stopping is the final stage of that, then CPR is not going to be successful.
You can’t reverse the whole body’s process of dying by attempting to restart the heart.
So it’s important to be able to have a conversation where you can explain that distinction, and explain why CPR would be unlikely to work.
I believe that we — doctors, patients, and their relatives — should start this important conversation very broadly, in a discussion about what outcomes the patient values and fears, instead of discussing particular treatments. When we talk about treatments, then doctors are expert: they know what each treatment entails, and can provide some statistical, population-based predictions on the chance of the treatment being effective. Even if the doctor explains this well, conversations about medical treatments demand that the patient (and/or those close to them) understands and processes often unfamiliar information.
If instead we start the conversation about what the patient is expert in — what they value and what they are afraid of — then they are given the opportunity to express themselves and to think about what they want without additional pressures of medical speak.
Dr Zoë Fritz
If a patient expresses a fear of a long-term hospital admission or being in a dependent state, then the doctor can recommend that some treatments — such as ones on intensive care which might lead to these outcomes, even though they might allow the patient to survive — are avoided.
If a patient expresses that they are happy to have whatever treatments are available, so long as they retain the ability to recognise their grandchildren, then the doctor can recommend more invasive treatments, but the patient can be assured that the doctors know what they value.
The three elements of shared understanding
There are three elements in the conversation that I think are important in terms of establishing shared understanding.
The first is the shared understanding of the patient’s condition
This requires both the patient and the clinician to have a shared understanding of the patient’s diagnosis, prognosis, and current situation. If you dive right in to a conversation about attempted CPR without having a shared understanding of what’s going on right now you’re going to have a meaningless conversation.
For example, sometimes when doctors use euphemisms they will go away thinking they’ve said one thing and patient and their relatives go away having understood something completely different.
Dr Zoë Fritz
Unfortunately, most of us as clinicians have examples of where we’ve said something like: “the only option available now is palliative chemotherapy” and we might think it’s been understood by the patient that therefore they are not going to get a cure for the cancer. But unless you’re explicit that might not have been heard.
The second key is to get a shared understanding of what outcomes the patient values and what outcomes they fear
I might say to a patient:
The patient might ask what I mean by that and I might say:
“For example, some patients have said to me:
‘I don’t want a lingering death. If my time comes please let me go quickly.’
But other people have said:
‘As long as I can wash myself a bit and recognise my granddaughter then keep me going.’“
These are really, really useful things to know. It’s not about asking which treatment you want:
- Do you want dialysis?
- Do you want invasive or non-invasive ventilation?
It’s impossible to go through all of those treatments. It’s about understanding overall outcomes. Then the doctor understands what the patient values, and can write it down in their words. In an emergency, in the event of a patient lacking capacity, doctors can then make decisions which respect those articulated values, and deliver treatments which will help get them to their desired outcomes, and avoid those that are feared.
The third thing is to get a shared understanding of what treatments might actually help that patient get to the shared outcomes.
You could say something like:
“In view of what you’ve just told me, I think we should give you antibiotics and fluids, and we should give you all the simple treatments on the ward.
But given that you’ve told me you wouldn’t want a lingering death, I think if those aren’t being successful, we shouldn’t take you to intensive care and we shouldn’t attempt CPR.
If we’re not managing to get you better with simple treatments we should make sure we allow you to die peacefully.”
To summarise, I think to discuss CPR you need to have a good conversation, and that conversation needs to achieve shared understanding of the patient’s condition, shared understanding of the outcomes that patient values and the outcomes they fear, and a shared understand of what treatments will realistically get them to the place they want to be. And as a tiny corner of that, you have to discuss CPR.
An alternative to a form which only focuses on CPR decisions is the ReSPECT process. It stands for Recommended Summary Plan for Emergency Care and Treatment, and it does what it says on the tin. It is a process which nudges clinicians, patients, and their families to have the kind of conversation I’m talking about — to try and achieve a shared understanding of the patient’s current condition, what outcomes they value, and what treatments can get them there — which can then be easily recognised in an emergency. So ambulance clinicians, GPs, and doctors in hospitals can all recognise what the overall treatment plan is.
If we are to change the culture of DNACPR, we must first focus on developing a shared understanding of each person’s unique situation and preferences and then have an individualised discussion which includes CPR decisions within the context of a wider plan for that person’s treatment and care.
If you’d like to join the conversation, why not find Zoe on Twitter, talk to us in Twitter, or leave a comment.