posted on Mar, 6 2013 @ 03:18 PM
I have noticed on ATS that many people have some very strong views on the various “Do Not Resuscitate” policies hospitals have and cases where
staff have not attempted CPR. As such I think it is time to have a thread like this one, let’s talk about CPR and DNR.
To be clear, I am a nurse, I have quite a lot of experience in administering CPR in A&E (the ER if you’re a American) and other hospital settings. I
have been involve in decisions about not giving CPR and going beyond CPR to a full blown resuscitation attempt that lasts hours on patients of all
ages in a desperate fight to save their live. I
I think it is important to highlight early on in this thread that unless you have been trained to do so don’t try some of the techniques that will
be discussed in this thread. It is also important to understand early on that every patient is different as is their care and I probably won’t be
able to comment on the right and wrong specific cases.
So to start with I want to talk about the myths of CPR
It’s probably best to start by explaining some myths about CPR. I blame many of the misconceptions around CPR on TV shows like ER and Casualty. Any
of you who will have seen TV probably know the routine, a big drama and some poor souls heart stops, rushed into hospital with paramedics providing
CPR then there is some nurse shouting that the patients is “flat lined” and is “asystole” so they start CPR shock the guy and at the end of
the show he is sitting up on bed eating some toast reflecting on his ordeal.
That is so far from the reality of what actually happens its laughable, CPR is not some magic touch it is a common misconception to assume that CPR
“restarts the heart”, that is incredibly rare and even rarer that someone will survive such an event. People should not assume that CPR is
anything like in the movies or even like what they might have once showed you on a manikin (ResusAnnie in my mind is a joke).
Do Not Resuscitate
Before we get into talking about who we do CPR in hospitals, lets first talk about the DNR policies, this is specific to my experience in the NHS in
the UK so other countries will differ but on the whole everywhere has some kind of DNR policy. The decision to not resuscitate an individual is
unbelievably complex it relies on medical staff liaising with the patient and the patients families.
That is actually where the problems start, with the families, people want their mum or dad to live its only natural and perfectly understandable. The
problem is that families have to realise they don’t have the final say and sorry but neither does the patient, the final say is with the doctor. If
a 90 year old man states that he wants CPR but he has metastatic cancer and multiple core morbidities the medical staff will over ride this decision
in most cases and put in a DNR form against his wishes and possibly also the families. To many of you that might seem shocking but a more in-depth
understanding of the system will show you otherwise.
At times the decision to attempt CPR is made in a split second, you literally have seconds to decide if CPR is appropriate or if it is not. What deems
if it is appropriate or not is based on a number of factors primarily the patient inform of you but also what you know about the patient if you have a
46 year old mother of 3 who is fit and health who you find collapsed in a supermarket yes CPR is appropriate. If you have the same 46 year old mother
of three who has end stage motor-neurons disease who has been in and out of ICU for years whose heart stops then it’s not so appropriate. Each case
In many cases the job of nurses is to provide palliative care, we have specialist palliative care nurses who job it is to care for patients who are
approaching death. We have things like the Liverpool Care Pathway that enables us to make a individuals death as comfortable as possible. The DNR is a
valuable component of palliative care many patients welcome discussions around death to help them cope with facing their own mortality. A nurses Job
is not only to save a live but also to care for a person who is dying and let them die.
I personally have not done CPR on an elderly lady who did not have a DNR from in place because I deemed it to be in appropriate, the ethics committee
of the hospital agreed with me. I used my clinical judgement and after quickly consulting my colleagues decided not to go ahead with CPR. Rather I
held her hand and she passed away peacefully.
Sometimes however, actually lots of times, CPR is attempted.
The problem with peoples perceptions of CPR is their own ignorance, it is not some magic touch.
The aim of CPR is not to actually to restart the heart (although in rare cases it can do so), rather the aim of CPR is to maintain some level of
oxygen to the cells of the body before the die until another medical intervention usually an electrical shock which might restart the heart. The
problem with that however is that contrary to what your TV is telling you there are only some heart rhythms that are “Shockable rhythms” (such as
a AF). When we say someone has had a Cardiac arrest and is in asystole after say a massive heart attack medical staff will have to continue CPR until
they push the heart into one of these shockable rhythms. Without being hit with the defib the chances of survival are incredibly slim, almost nobody
survives from a cardiac arrest with just CPR alone and after three minutes of no CPR the brain will already be hypoxic
There are lost of other things that go on we will also have to perform a rapid sequenced intubation, basically sticking a tube down someone’s
throat. They will require big, and I mean big needles in their arms but if we can’t get to them because the circulation has shut down that causes
other problems. The patient will be on various monitoring most importantly SPo2, something we call continuous cardiac monitoring (other places have
different names) and blood pressure monitors (there can be much more than these three depending on the setting). In addition to this the will probably
require some inotropic drugs such as Adrenalin or dopamine. I could probably go on about this all day but that is what is done with a very basic
arrest, and doesn’t even start to talk about “reversible factors”.
To the Arm-Chair nurses.
This is a phase I have coined for individuals who accuses nurses and doctors for that matte as “murderers” for not attempting CPR. Just like
it’s a bit stupid to a solider for you to say to him “well you could have shot the suicide bomber on the leg”, its also a bit stupid to say to a
nurse that “well you could have done CPR on the 88 year old with chronic heart failure”. This issue that many people fail to realise is that CPR
in lots of cases is not in the best interest of the patient, as nurses we seek to preserve quality of live. There is no dignity for a 88 year old who
receives CPR only to live out her last days hooked up to life support only for medical staff to switch it off in the end.
Death is a inevitability of life, we can only prolong it for so long before we have to let nature take is course and accept death.
So please feel free to ask questions and discus the points I have raised but please refrain from calling me or my colleagues “murderers”.