Advance CPR decision making
Narrator/Doctor: To think that dying is failure is going to colour everything that you do.
The issues
The framework
The communication
Narrator: Resuscitation for those with hearts too good to die has been a success story but pioneers never intended that CPR be applied to all patients in all settings.
The Resuscitator: What has happened is that we’ve gotten into this pattern of resuscitating anyone and everyone whether it is in their best interests or not.
The Professor: The fundamental problem is that a lot of the interventions that we commonly use in medicine have been developed on a single issue or a single problem.
Narrator: Patients are dying more commonly in hospital with chronic conditions that respond less well to treatments. Doctors may not identity the trajectory the patient is on or discuss with patients about end of life issues including resuscitation. In hospitals the default position may not be appropriate.
Ward based CPR Footage
Have we confirmed cardiac arrest? Yes we have.
The Intensivist: I still make calls frequently when no end of life decisions have been made despite the fact that the patient is on a deteriorating pathway.
The Key Opinion Leader: We delude ourselves into thinking that we are good at this - we actually aren’t.
Clinical Leader: Patients have a very falsely high exaptation of success of resuscitation.
Doctor: I think we all have a role to play.
Registrar: At the moment there is probably a lack of consistency and a lack of across the board consistency with how consultants approach these discussions and conversations.
The Intensivist: The main problem is us.
Narrator: Doctors have not been well trained in communicating or making these decisions.
Ward based CPR Footage
Oxygen away. Charging. Top clear. Middle clear. Bottom clear. I’m clear. Hands on compressions. Okay we’re still in asystole, can we dump the charge? And can we continue with CPR.
The Communicator: Doctors and clinicians struggle with conversations, particularly these difficult ones.
The stuff up
Discussion with patient and Doctor: If your heart stops are you wanting us to start it up again?
Of course I do. Of course I do. Yeah.
Narrator: This can be improved by applying a consistent approach for those who are not in the default position. It’s time for a framework to guide assessment and communication with the patient, family and carer.
Doctor: If the patient cannot survive CPR then we should not be offering it.
Applying the research
The Generalist: Identifying patients who won’t survive CPR, it’s not black and white. Most of the research has been about how to do it in the technical aspects, not who to do it on.
The Intensivist: A discussion about CPR is embedded in a discussion about your life, your values, your illness and your expectations and is a part of an ongoing conversation
Clinical Leader: You can’t discuss CPR without discussing life and death.Registrar:
We could do with a lot more consultation and guidance in this area.
Ward based CPR Footage
Can we please remove all of the monitors we need to pronounce this lady dead. Sure.
It’s all about communication
Narrator: Communication is a learnt skill. As the cornerstone of medical care all medical doctors should strive to improve their communication. This can be achieved through reflective practice, use of tools and workshops.
When it’s done right
Discussion with Patient and Doctor
Patient: I’m a bit worried that your breathing isn’t getting better the way that we would expect.
Doctor: Well, yes, but it’s been like that before, I’ve bounced back, gone home, seen the grandchildren.
Narrator/Doctor: You know that you’ve achieved something when you actively listen to the person and that they feel actively listened to. Patient:
Well, I do know it’s getting bad, but how far I don’t know. What do you think, what can we do?
Clinical Leader: They need to be able to trust that we have their best interests at heart and for CPR they also need to be able to trust if they have an order to withhold CPR that we still will be able to provide high quality care and that doesn’t mean they’ll miss out.
Patient: I kind of know deep inside that this happening.
The Generalist: And they’re much more likely to make decisions that are in their own health interests and have a good outcome, a good experience of health care, but also a good death if their time is up.
Narrator/doctor: If the family has had the discussion; if the level of understanding and knowledge is high then you’ll find that you’ll have extremely strong support and strong advocacy for making your decision.
Narrator: Videos, resources and a facilitator’s guide are available to support educators.
ENDS