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Decisions about cardiopulmonary resuscitation

April 2008

To help the process of informing patients about what CPR is, and how decisions about it are made, the BMA has written a model information leaflet for patients. It addresses the questions patients ask, or might want to ask, about how resuscitation decisions are made.

The leaflet is endorsed by the Resuscitation Council (UK) and the Royal College of Nursing. The text has been awarded a Crystal Mark for its plain English.

The leaflet is available in text (below) and in unformatted Word and a pdf version is available as a reference tool. Use the links on the right to download. We are waiving copyright, and hope that health care establishments that need to provide patients with information about CPR will use the text as the basis for their own leaflets, by taking the relevant questions and adding in local information.

Model information leaflet
This leaflet explains:

• what cardiopulmonary resuscitation (CPR) is;
• how you will know whether it is relevant to you; and
• how decisions about it are made.
• It is a general leaflet for all patients but it may also be useful to your relatives, friends and carers. This leaflet may not answer all your questions about CPR, but it should help you to think about the issue. If you have any other questions, please talk to one of the health professionals (doctors, nurses and others) caring for you.

What is CPR?
Cardiorespiratory arrest means that a person’s heart and breathing stop. When this happens, it is sometimes possible to try to restart their heart and breathing with emergency treatment called CPR.
CPR might include:
- repeatedly pushing down very firmly on the chest;
- using electric shocks to try to correct the rhythm of the heart; and
- inflating the lungs with a mask or tube inserted into the windpipe.

Is CPR tried on everybody whose heart and breathing stop?
Yes, in an emergency if there is a chance that it will work and the person has not refused CPR. When the heart and breathing stop without warning, for example if a person has a serious injury or heart attack, the healthcare team will try to revive the patient. Some members of the public are also trained to do CPR. The priority is to try to save the person’s life.

A person’s heart and breathing also stop working as part of the natural and expected process of dying. If people are already very seriously ill and near the end of their life, there may be no benefit in trying to revive them each time their heart and breathing stop. This is particularly true when patients have other things wrong with them that mean they don’t have much longer to live. In these cases, re-starting their heart and breathing may do more harm than good by prolonging the pain or suffering of a terminal illness.

Do people get back to normal after CPR?
Each person is different. A few patients make a full recovery, some recover but have health problems and, unfortunately, many attempts at CPR do not restart their heart and breathing despite the best efforts of everyone concerned. It depends on why their heart and breathing stopped working and the patient’s general health. It also depends on how quickly their heart and breathing can be restarted.

Patients who are revived are often still very unwell and need more treatment, usually in a coronary care or intensive care unit. Some patients never get back the level of physical or mental health that they enjoyed before the cardiorespiratory arrest. Some have brain damage or go into a coma. Patients with many medical problems are less likely to make a full recovery. The techniques used to try to restart the heart and breathing sometimes cause side effects, for example, bruising, fractured ribs and punctured lungs.

Am I likely to have a cardiorespiratory arrest?
Only your healthcare team can advise you on the likelihood of you having a cardiorespiratory arrest. Even when they have the same symptoms, people respond differently to illness, and planning what will happen if they have a cardiorespiratory arrest is a normal part of providing good care for many patients. Somebody from the healthcare team caring for you, probably the healthcare professional in charge, will talk to you about:

• your illness;
• what you can expect to happen; and
• what can be done to help you.
• What is the chance of CPR reviving me if I have a cardiorespiratory arrest?
• The chance of CPR reviving you will depend on:
• why your heart and breathing have stopped;
• any illnesses or medical problems you have (or have had in the past); and
• the overall condition of your health.
• Attempted CPR in hospital is successful in restarting the heart and breathing, so that about 2 out of 10 patients survive long enough to leave hospital. The figures are much lower for patients with serious underlying conditions. It is important to remember that these only give a general picture and not a definite picture of what you personally can expect. Everybody is different and the healthcare team will explain what CPR could do for you.

Does it matter how old I am or that I have a disability?
No. What is important is:

• your state of health;
• your wishes; and
• the likelihood of the healthcare team being able to achieve what you want.

Your age alone does not affect the decision, nor does the fact that you have a disability.

Will I be asked whether I want CPR?
You and the healthcare professional in charge of your care will decide whether CPR should be attempted if you have a cardiorespiratory arrest. The healthcare team looking after you will look at all the medical issues, including whether CPR is likely to be able to restart your heart and breathing if they stop, and for how long. It is beneficial to attempt resuscitation if it might prolong your life in a way that you can enjoy. Sometimes, however, restarting people’s heart and breathing leaves them with a severe disability or prolongs suffering. Prolonging life in these circumstances is not always beneficial. Your wishes are very important in deciding whether resuscitation may benefit you, and the healthcare team will want to know what you think. If you want, your close friends and family can be involved in these discussions.

What if I don’t want to decide?
You don’t have to talk about CPR if you don’t want to, or you can put discussion off if you feel you are being asked to decide too much too quickly. Your family, close friends and carers might be able to help you make a decision you are comfortable with. Otherwise, the healthcare professional in charge of your care will decide, taking account of your wishes.

If you are under 18 (16 in Scotland), your parents can decide for you.

What if I am unable to decide for myself?
England and Wales
Adults can choose somebody to make decisions for them (a ‘proxy’) if later they cannot make decisions for themselves. If you have not formally chosen a proxy the healthcare professional in charge of your care will make a decision about what is best for you. Your family and friends are not allowed to decide for you but it can be helpful for the healthcare team to talk to them about your wishes. If there are people you do (or do not) want to be asked about your care, you should let the healthcare team know.

Northern Ireland
The healthcare professional in charge of your care will make a decision about what is best for you. Your family and friends are not allowed to decide for you. But it can be helpful for the healthcare team to talk to them about your wishes. If there are people you do (or do not) want to be asked about your care, you should let the healthcare team know.

Scotland
Adults can choose somebody to make decisions for them (a ‘proxy’) by contacting a solicitor if they cannot make decisions for themselves. If you have not formally chosen a proxy the healthcare professional in charge of your care will make a decision about what is best for you. Your family and friends are not allowed to decide for you. But it can be helpful for the healthcare team to talk to them about your wishes. If there are people you do (or do not) want to be asked about your care, you should let the healthcare team know.

I know that I don’t want anyone to try to resuscitate me. How can I make sure they don’t?
If you don’t want CPR, you can refuse it and the healthcare team must follow your wishes. You can make a living will (also called an ‘advance decision’) to put your wishes in writing. If you have a living will, you must make sure that the healthcare team knows about it and puts a copy of it in your records. You should also let people close to you know so they can tell the healthcare team what you want if they are asked.

If it is decided that CPR won’t be attempted, what then?
The healthcare team will continue to give you the best possible care. The healthcare professional in charge of your care will make sure that you, the healthcare team, and the friends and family that you want involved in the decision know and understand the decision. There will be a note in your health records that you are ‘not for cardiopulmonary resuscitation’. This is called a ‘do-not-attempt-resuscitation’ decision, or DNAR decision.

What about other treatment?
A DNAR decision is about CPR only and you will receive all the other treatment that you need.

What if I want CPR to be attempted, but the healthcare professional in charge of my care says it won’t work?
Although nobody can insist on having treatment that will not work, no healthcare professional would refuse your wish for CPR if there was any real possibility of it working successfully and helping to bring you back to good health. If there is doubt whether CPR might work for you, the healthcare team will arrange a second medical opinion if you would like one. If CPR might restart your heart and breathing, but is likely to leave you severely ill or disabled, your opinion about whether these chances are worth taking is very important. The healthcare team must listen to your opinions and to the people close to you if you want them involved in the discussion. In most cases, healthcare professionals and their patients agree about treatment where there has been good communication.

What if my situation changes?
The healthcare team will review decisions about CPR regularly and especially if your wishes or condition change.

What if I change my mind?
You can change your mind at any time, and talk to any of the healthcare team caring for you.

Can I see what’s written about me?
Yes, you can see what’s written about you. You can ask the healthcare team to show you your records and, if there is anything in them that you do not understand, they will explain it to you. You also have a legal right to see and have copies of your records.

Who else can I talk to about this?
[Contact information to be added locally. Wherever possible, direct contacts to be given so that the healthcare team is not the “gatekeeper” to further support.

• Counsellors
• Spiritual carers (such as a chaplain)
• Independent advocacy services
• Patient support groups]

If you feel that you have not had the chance to have a proper discussion with the healthcare team, or you are not happy with the discussions you have had, please contact … who can help you or the people close to you and deal with your suggestions, worries or complaints.


For further information about this leaflet

BMA members may contact:
askBMA on 0870 60 60 828 or
British Medical Association
Department of Medical Ethics, BMA House
Tavistock Square, London WC1H 9JP
Tel: 020 7383 6286
Fax: 020 7383 6233
Email: ethics@bma.org.uk

Non-members may contact:
British Medical Association
Public Affairs Department, BMA House
Tavistock Square, London WC1H 9JP
Tel: 020 7387 4499
Fax: 020 7383 6400
Email: info.public@bma.org.uk

Royal College of Nursing
20 Cavendish Square
London W1G 0RN
Tel: 020 7409 3333

Resuscitation Council (UK)
5th Floor, Tavistock House North
Tavistock Square, London, WC1H 9HR
Tel: 020 7388 4678
Fax: 020 7383 0773
Email: enquiries@resus.org.uk