Video transcript Part B Advance CPR decision making overview

Doctor <15% survival - Associated disability (can be severe)

Treated cardiac arrest survival

• 100% with coronary angiography (elective)
• 60% for VF in CCU after myocardial infarct
• 18% for general hospital patients *
• 5% for advanced illness – cancer, dementia etc*

*30-50% of these survivors will have further impairment.

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

I think it is a little different umm because of people's expectations the ahh patients ah and their families often think CPR is standard treatment and should always be given. Ahh and also we teach CPR as first-aid treatment in the community, for everybody who has a cardiac arrest so we've created a very high expectation that CPR will always be provided and so we need to often raise this, even if not going to provide CPR.

Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health

Is it a life-and-death decision? Is that how we should frame it with our patients?

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

I think CPR does seem to be very much a life-and-death decision. You can't discuss CPR without discussing life-and-death. You can have discussion about other treatments without discussing death, but not CPR. So it's a high-stakes decision, umm, and the potential for it to result in a perhaps a life that is even worse than death is often not considered by the patient and family. The stakes are high and trust becomes important.

Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health

So it's really no surprise, we've got a high-stakes discussion with patients with a high expectations of a good outcome and we know it's gonna be poor, but for some patients CPR being the default position is appropriate and on those who it is designed for. Can you tell me about that group?

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

Well in hospitals of course unless there's an order not to provide CPR we provide CPR and now for many patients that will be appropriate, particularly young people with just an acute illness but not umm a lot of co-morbidities, patients ah who've had acute myocardial infarct or acute cardiac ischemia have some very successful outcomes from CPR.  They are already being monitored in coronary care, ah if they have ventricular fibrillation they may have up to a 60 percent chance of survival. This is what CPR was designed for. I guess the other group would be people having surgical procedures having an anaesthesia with their umm, their functions being taken over by an anaesthetist already. 

In the Emergency Department 

[ED Male Staff Member] Are we getting good movement on both sides of the chest? Are you bagging?

[Nurse Off screen] Okay.

[ED Male Staff Member] … looks like yep good yeah it looks like we have good tension in the thorax.

Part B

Is CPR decision-making different?

The medical assessment

Four clinical categories + discussion aim

Dr Peter Saul, Intensive Care Specialist John Hunter Hospital, NSW

A decision about CPR is embedded in a discussion about your life, your values, your illness your expectations and is part of an ongoing conversation. It's not umm a tick box approach, it's not CPR or no CPR yes tick the box, it’s actually who is this person, what is their expectation? Where is their illness going and what are they hoping for?

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

The first question we need to ask ourselves is - would this patient survive CPR? Because if the patient can’t survive CPR then we should not be offering it, because it won't change the outcome.

What to consider when assessing patient survival

Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health

Identifying patients who won't survive CPR, it's not black and white. Most of the research has been about how to do it and the technical aspects, not who to do it on.

Dr Jacqueline Donnelly, Intensive Care Consultant, Armadale Health Service, WA

I think they need to consider the patient and all aspects of the patient; what's wrong with them now?; what their co-morbidities are and what level their co-morbidities are?; what are their lifestyles like?; how's their mobility?; are they living independently? They also need to consider, umm, where they think they will be going with CPR and what levels of treatment they're currently on. Would CPR actually add to that treatment level?

Professor Leon Flicker, Director WA Centre for Health and Ageing, Royal Perth Hospital, WA

It can be very difficult to diagnose when somebody's dying. The trajectory can be different for different conditions and we’re often uncertain about where somebody is in that trajectory.

Frailty indicates a lack of physiological reserve.

Dr Nicholas Waldron, Clinical Leader &Consultant Geriatrician, WA Health

(Voice Over) To survive and recover from CPR a person must have adequate physiological reserve. This can be considered in a number of ways. Ask yourself: Would I be surprised if this person died within the next twelve months? Does this person have chronic progressive illness? Are general indicators present, including: reducing function, unplanned hospital admissions, weight loss, refractory symptoms or increasing dependency? These indicators can assist in determining where the person is on their illness trajectory. Are they experiencing a short period of evident decline, as seen with cancer? Are they deteriorating, with reducing function and experiencing frequent exacerbations such as seen in cardiac and lung disease? Are they deteriorating with brain failure or generalised frailty of multiple body systems, with a long and often variable trajectory? Frailty tools and other prognostication tools such as SPICT can provide insight and highlight that physiological reserve and the ability to survive and recover from CPR may be lacking.

Professor Leon Flicker, Director WA Centre for Health and Ageing, Royal Perth Hospital, WA

Those scales are all good and one of the problems is that we still have a little bit of uncertainty on top of it but the scales themselves are an aide memoir - they help us remember to look for things and to consider things.

The Emergency Department

[ED Male Staff Member]  Okay we're getting back towards two moves.  Can we please charge the defib again please?

[Vicky] Compressions continue, everyone else stand clear, oxygen away. Charging, cot clear, middle clear, bottom clear, I'm clear [flat line sound] Hands off compressions.

[ED Male Staff Member]  Okay that is still asystole, can you dump the charge?

[Vicky] Charging. 

[ED Male Staff Member]  ....and can we continue with CPR.

Part B

Is CPR decision-making different?

The medical assessment

Four clinical categories + discussion aim.

Dr Nicholas Waldron, Clinical Leader &Consultant Geriatrician, WA Health

You found two categories that people won't survive CPR. Can you tell me about that?

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

I identified two categories: One, patients who were actually dying and the second-category are patients who are not dying but are very frail and fragile and we know would not survive CPR. If you perform CPR for these patients it merely converts a gentle dying into a bad dying.

Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health

So for those who are dying it wouldn't seem sensible to be talking about CPR. How should we approach this conversation?

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

I don't think this is a discussion about CPR, I think this is a discussion about dying. Explaining what normal dying looks like.

Discussion: Good dying.

Disagreement: Work to increase Trust. Provide CPR or refuse?

Dr Nicholas Waldron, Clinical Leader &Consultant Geriatrician, WA Health

And the category where they are unwell and not likely to survive, umm, but they may not die on the ward as well so it is not imminent. How do we approach this group?

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

This is a discussion about CPR. It's a discussion about how unwell patient is and making sure that there's an understanding that the patient might have a cardiac arrest because of their unwellness and if that happened we wouldn't be providing CPR because it could not be effective.

Discussion: Good dying or bad dying: not life

Disagreement: As for dying patient

Mr Frank Prokop, Executive Director, Health Consumers Council of WA

What might seem to the doctor to be a simple and rational and medically responsible decision, can be challenging for the family because if things don't work out they may have lost a loved one and they will always ask the question about what their role and responsibility is.

The Emergency Department

[ED Male Staff Member]   Okay Vicki so I think I've done the four H's what about the four T's? So we've done tension pneumothorax, temponade, temperature and thrombo embolic. Can you just check her legs to see if there's [Vicky: sure] any evidence of DVT or anything?

[Vicky] Mmhmm.

Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health

If we move to the patients that may survive CPR and I understand on a medical ward it's between zero and 18 percent. We’ve talked about the zero percent group, what about those who are quite frail and not that unwell but we think they likely have a pretty poor outcome.  How should we approach the discussion with this group?

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

This is as a group where CPR may be appropriate but we will generally be recommending that we don't provide CPR because here the risks of harm and ahh in terms of dying during CPR or having impaired function afterwards start to outweigh any potential benefits. 

Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health

So when you look at the statistics and only two percent would have survival at a reasonable functional level I guess it's really important to make sure that the goals of the patient have been clarified. Are they prepared to take this risk because those odds for many will be unacceptable?

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

That's right, although some people will have a different way of valuing CPR and may choose to take those risks and say that's okay for them.

Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health

In the fourth category, the group who again they're going to have a fairly poor outcome and maybe they've got a five percent or four percent chance of surviving the level of function they umm start with.

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria 

These patients, ah, I think it's a discussion like any other umm high-risk medical treatment. Discussing the benefits and burdens of CPR or no CPR in a way that makes sense to the patient context, not just the statistics, but helps them to understand what those outcomes could be and we should arrive at a shared understanding of what's going to be best for the patient.

Documenting the conversation

Use local forms and follow local procedures

Write more than less

Capture

Goals of care

Escalation plan

Dr Peter Saul, Intensive Care Specialist, John Hunter Hospital, NSW

It’s important to document the conversation you've had even if the conversation seems a little bit wide ranging. There are two things you have to capture. One is the patient's goals, values and expectations but also something practical about what we're actually going to do in this current system that is intelligible to a nurse who reads this document at two o'clock in the morning.  

The Emergency Department

[ED Male Staff Member]   Okay, just change at the end of the cycle…

[Nurse] 28, 29, 30... Okay you're coming up to two minutes now.

Dr Kieran Lennon, Intensive Care Consultant

Although they may survive the cardiac arrest their eventual outcome is going to be very poor and often they will spend a prolonged period of time either within the intensive care units and then die or spend a prolonged period of time in the hospital and not get out of hospital. Or even if they do get out the hospital they get out of hospital with a very, very poor quality life and never get back to life they previously had.

Approaching communication = two sets of experts

Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria

In any medical decision-making we have two sets of experts. We have the experts on the patient umm who are the patient and the family. We have the experts on the medical treatment, the clinicians. Together we bring those two expertise together to come to shared understanding of what's going to be in the best interests of the patient.  Having a realistic understanding of the limits of what medicine can do, to actually keep you well might then allow you to say, well actually if you can't do a lot for me ahh to keep me well I would rather be at home in my own surroundings to die in my own way.

Dr Peter Saul, Intensive Care Specialist, John Hunter Hospital, NSW

So we would urge the doctor to take time, to ask questions that enable the partnership to be developed and for the family and carers to understand that both the doctors and the family are in this together.