“Patients suffer needless heart attacks in hospital”, Channel 4 News has reported, while the Daily Mail has said, “Do not resuscitate orders 'ignored' as doctors try to revive patients suffering cardiac arrest”.
The news is based on the findings of an important independent investigation of patient care. Although Channel 4 and the Daily Mail headlines differ, they reflect the wider media coverage, which is largely focused on criticising doctors for being too ‘quick to resuscitate’ or ignoring patients’ wishes.
The investigation by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) looked at the care of 526 patients who had a cardiac arrest and underwent a resuscitation attempt in NHS hospitals in England and Wales over a two-week period in 2010.
‘Cardiac Arrest Procedures: Time to Intervene?’ looked at areas where patient care could have been improved, including factors affecting decisions to resuscitate an acutely ill person. It found that more than one-third of cardiac arrests could have been prevented and recommended improving patient assessment and responding adequately to the patient’s deterioration. NCEPOD also found that decisions about a patient’s CPR status are not always documented clearly.
The NCEPOD report appraises the circumstances surrounding patients who received CPR for in-hospital cardiac arrest and aims to identify areas where patient outcomes can be improved. The media coverage focused on one of the conclusions criticising doctors for being too ‘quick to resuscitate’. However, the report’s main conclusions were:
- that care should be focused on preventing cardiac arrests, through appropriate management of acutely ill people to maximise their chance of recovery
- that decisions about when to resuscitate should be consistent to ensure that resuscitation is only performed on patients who are likely to gain the most benefit
This report serves as an important reminder to people going into hospital, and their friends or family carers to make sure that professionals involved in their care are aware of the patient’s wishes.
What is cardiopulmonary resuscitation?
Cardiopulmonary resuscitation (CPR) is an attempt to sustain the life of someone whose heart and/or breathing have stopped. The NCEPOD report said that CPR had been developed to save the lives of younger people dying unexpectedly, but that it has come to be used in cardiac arrests irrespective of the underlying cause. The report highlighted the fact that rates of survival and recovery following cardiac arrest in hospital are as low as 20%, meaning that many attempts at CPR may be ‘futile’.
Where CPR may not be medically appropriate (for instance, if a patient is too ill and is unlikely to respond to resuscitation), the medical team should discuss this with the patient and their family, and a “Do Not Attempt Resuscitation” (DNACPR) decision made and documented. This is to prevent patients having to undergo unnecessary attempts at CPR while they are dying. Some people will prefer doctors to make every effort to save them, while others may say they would prefer a dignified death without intervention.
According to the research carried out by NCEPOD, a large number of people who have died in hospital from cardiac arrest have had CPR attempts even when their underlying condition and general health made success unlikely. NCEPOD found that for patients where a cardiac arrest or death is likely, decisions about a person’s CPR status were often not documented.
What are the warning signs of a cardiac arrest?
The report said that many in-hospital cardiac arrests are predictable and that these ‘predictable’ cardiac arrests are not caused by heart disease, but instead, often follow a period of slow and progressive physiological deterioration. The report said that this is often poorly recognised and treated.
NCEPOD’s advisors from across the health professions considered that there were warning signs that a person’s health was deteriorating in 75% of deaths from cardiac arrests. However, they found:
- warning signs were not picked up in 35% of patients
- not acted upon adequately in 56%
- and not communicated to senior doctors in 55% of cases
NCEPOD’s advisors considered that cardiac arrest was predictable in 64% of cases and potentially preventable (through appropriate medical management) in 38% of cases in this study.
These findings come despite National Institute for Health and Clinical Excellence (NICE) guidelines from 2007 that set out the recognition and appropriate management of acutely unwell patients.
How can more cardiac arrests be prevented?
The report recommended that to prevent cardiac arrests, hospitals must better plan each patient’s care and staff must ‘escalate’ their care to a senior doctor when there are signs of deterioration in a patient’s health.
Report author Dr George Findlay, NCEPOD’s lead clinical co-ordinator, said, ‘The recognition of acute illness, response to it and escalation of concerns to consultants when patients are deteriorating, is not happening consistently across hospitals’. He added, ‘Senior doctors must be involved in the care-planning process for acutely ill patients at an earlier stage and support junior doctors to recognise the warning signs when a patient is deteriorating’.
What did the report find about ‘do not resuscitate’ orders (DNACPR)?
NCEPOD’s report found that decisions about CPR status were documented in the admission notes of only (10%) people who had a cardiac arrest in hospital (44 out of 435 cases where data was available for admission details prior to the first consultant review). This happened despite the high rate of chronic disease among these people at the time of admission, with almost one in four cases expected to be potentially fatal. NCEPOD’s advisors believed that a further 89 of the 435 patients should have had a DNACPR decision made at the time of their initial admission and treatment.
Overall, 22% of patients (122 out of 552 cases where the treating consultant had been asked by questionnaire whether there was a CPR status in people’s notes) had their CPR status documented in their medical notes (at admission or later). Of these, 70 were documented for CPR and 52 for DNACPR. Therefore CPR was attempted on 52 people who had a documented do not attempt resuscitation (DNACPR) decision. Of these 552 patients, 78% had no documentation about CPR status before CPR was performed. Interestingly, following a cardiac arrest 44% of patients subsequently had a DNACPR decision made.
How could care be improved?
NCEPOD’s report said that healthcare staff should quickly identify patients whose life cannot meaningfully be prolonged by CPR, but for whom CPR would merely prolong their death.
CPR status should be recorded for all acutely ill patients during the initial admission period or soon after. Any decisions about CPR - to resuscitate - or DNACPR – not to resuscitate - should be clearly documented. The report further identified areas for improvement in preventing cardiac arrests that included:
- consultant (senior doctor) involvement
- decision making about CPR status
- appreciation of urgency and involvement of more senior doctors
- recognition of severity of illness
What else does this report recommend?
NCEPOD recommended that care should be focused on preventing cardiac arrests happening. This should be done by appropriately managing acutely ill people. Secondly, NCEPOD said decisions about when to resuscitate should be consistently applied and communicated to ensure that resuscitation is only performed for patients who are likely to gain from it.
The report also recommended that when acutely ill patients continue to deteriorate after a medical review, they should be seen by a more senior doctor. It also stated that each hospital should have an agreed plan for airway management during a cardiac arrest and that hospitals review all CPR attempts.