In the Midst of Life (52 page)

For example, if a patient is in the last few weeks of life, then drugs such as analgesics should be available in the person’s home in case they are needed. This can prevent a crisis if these drugs are required at short notice. Depending on the patient’s condition, the coding is reviewed regularly to take into account any changes.

The majority of GP practices in England have now adopted the GSF in some format, but how it is adopted and adapted depends on individual GP practices.

Choice
and misconceptions about CPR

Patient choice is high on the health and social care agenda (Department of Health 2008; 1991; Mental Capacity Act 2005) but this can lead to patients being offered unrealistic choices that are not supported by expert professional opinion. The wrong choice can result in a negative outcome for the patient.

In my experience, there is a misconception among some nurses, doctors and patients that all patients/carers should be given a choice about resuscitation.

Many nurses will have experience of doctors entering a patient’s room when they are in the last few days of life and asking the family carers: ‘If your relative’s heart and lungs stop working, do you want us to resuscitate them?’ In some situations, the family carers are adamant that they do not want this. However, where death is approaching much more quickly than expected, or when it has been difficult for family carers to accept their relative’s approaching death, they may decide that they want CPR.

This can leave healthcare professionals with an ethical dilemma – the family carers want everything to be done, but CPR itself is not an appropriate intervention, so what should they do when the patient dies? The choice is to initiate CPR or to risk a complaint and possible litigation if they do not.

CPR guidance from the BMA
et al
(2007) does not help healthcare professionals with this dilemma. It states that if patients insist they want CPR, even if it is deemed to be futile, it should be carried out but, when an arrest occurs, the situation should be reviewed. In reality, this means that the patient is offered an intervention that will not be given. This does not support a trusting relationship between healthcare professionals and the patient (Bass, 2008).

Patients or family carers cannot demand CPR and healthcare professionals are not required by law to give a futile treatment. So why is CPR offered at the end of their life when other interventions, such as surgery, would not be considered?

The National Council for Palliative Care (2002a) states that: ‘There is no ethical obligation to discuss CPR with the majority
of patients receiving palliative care for whom such treatment, following assessment, is judged futile.’

Written guidance on how to decide if someone is appropriate for CPR has been developed by Randall and Regnard (2005). They produced a flow chart that asks whether the person is expected to have a cardiac or respiratory arrest from a reversible or irreversible cause. If the cause is reversible and there is a chance that CPR would be successful, the patient should be asked whether they would or would not like it, should they go into cardiac or respiratory arrest. If the cause is irreversible and there is no chance of success from CPR, then it should not be offered.

Practice points

• End-of-life care does not have to be complex.
  
• Patients and family carers need to be kept informed about care plans.
  
• Keep the treatment plan simple by only offering interventions that are appropriate for that individual as this is less confusing.
  
• CPR should not be offered when it is deemed to be futile.
  
• Involve the multidisciplinary team in discussions about end of life.
  
• If your place of work does not have a Do Not Attempt Resuscitation (DNAR) policy, it is important to highlight this. All staff should also be aware of the BMA
  et al
  (2007) resuscitation guidelines. The National Council for Palliative Care (2002b) has published a document that offers guidance on how to write a local DNAR policy. If you work for an NHS trust, always consult your local policy and guidelines group.
  
• If there is a chance of successful CPR, then the intervention should be discussed with the patient. If the patient does not have capacity, then evidence of advance care planning, either written or verbal, should be sought. If there is no evidence of either, the patient’s representatives should be asked what they think the patient would want. Alternatively, an independent mental capacity adviser (IMCA) or a court of protection decision may be required.
  
• If CPR is
  not going to be successful, it should not be offered. The aims of care should be discussed with the patient.
  

Implications for practice

I would argue that nurses are not equipped through basic training to deal with the stress and psychological trauma that patients and family carers are dealing with at the end of life. Nurses develop these skills through experience, reflection and self-awareness. Nurses can support those who are at the end of life by:

• Refining their communications skills
  
• Offering appropriate interventions
  
• Checking the patient understands what is happening
  
• Using appropriate terminology.
  

Good communication skills

Good communication includes active listening – this is hearing what is said as well as paying attention to what is communicated in non-verbal ways such as body language.

It is not possible to guess how someone will feel about CPR as there are huge discrepancies between what we think patients want and what they actually want (Jevon, 1999).

We need to make sure that patients and families understand that saying no to CPR does not mean they are saying no to all interventions.

Offering appropriate interventions

Treatment interventions that are unlikely to be successful should not be offered.

The CPR guidelines state that each resuscitation decision should be discussed, where appropriate, with the individual or their representative (BMA
et al,
2007). However, ‘discussion’ does not necessarily mean asking the patient or family to make a decision. Discussion may involve talking things over, finding out what the person’s understanding of the current situation is, and outlining the treatment aims (Bass, 2006). This can be achieved by asking the question, ‘What is your understanding of what has been happening
to you/your relative up to now?’ Alternative questions such as ‘Are you the sort of person who likes to know what is going on?’ can be helpful.

These questions may show that the patient understands much more than first thought, or that they would rather you discussed interventions with someone else, for example their family or carers.

Check the patient’s understanding

Patients may have heard what has been said but have not retained the information. They may have difficulty taking in what has been said either because they cannot believe it, or they do not understand the terminology used. It is important to check a patient’s understanding and provide written information if appropriate to reinforce what has been said.

Using appropriate terminology

It may not be appropriate to use the term ‘resuscitation’ when discussing end-of-life care with patients. Simple phrases stating that at the time of death you will not attempt ‘anything heroic’, but will ‘do all we can to make sure you are comfortable’, are extremely useful.

Conclusion

By making sure we communicate well, and by using tools such as the GSF, LCPI, DNAR policies and advance care planning documentation, nurses can ensure that they are supporting their patients at the end of life.

Awareness of when CPR is appropriate and careful assessment and care planning by the multidisciplinary team will ensure that patients are only offered interventions that are beneficial.

References

Related
articles in Nursing Times

The
Principles of Palliative Care

Palliative care is governed by certain principles, which guide the care given. It:

• Provides relief from pain and other distressing symptoms
  
• Affirms life and regards death as a normal process
  
• Intends neither to hasten or postpone death
  
• Integrates the psychological and spiritual aspects of patient care
  
• Offers a support system to help the family cope during the patient’s illness and in bereavement
  
• Uses a team approach to address the needs of patients and their families, including counselling, if indicated
  
• Will enhance quality of life and may positively influence the course of the illness
  
• Is applicable early in the course of the illness, in conjunction with other therapies that may prolong life, such as chemotherapy or radiation therapy, and includes investigations needed to better understand and manage distressing clinical complications. (World Health Organization, 2004)