The British Medical Association [BMA], Resuscitation Council (UK) [RC (UK)] and Royal College of Nursing [RCN] note the findings of the Nursing and Midwifery Council’s Conduct and Competence Committee in January 2017, recorded at:
In summary, an experienced nurse, in charge at a nursing home, was called to a resident who had been found unresponsive. After finding the resident waxy, yellow, and almost cold, with no vital signs of life, she believed that she had already died, so did not attempt cardiopulmonary resuscitation (CPR) or call the emergency services. The resident did not have a DNACPR recommendation in place. The NMC determined that the nurse’s fitness to practise was impaired because of misconduct.
The BMA, RC (UK) and RCN are aware that this ruling has caused concern and considerable debate among nurses and other healthcare professionals, due to fear that they may be at risk of similar criticism or disciplinary action should they make a considered decision not to attempt CPR on a person who has features of irreversible death, or a person for whom CPR would offer no realistic prospect of benefit.
We wish to draw attention to wording in our jointly authored national guidance Decisions relating to cardiopulmonary resuscitation. This states in its main messages: ‘Where no explicit decision about CPR has been considered and recorded in advance there should be an initial presumption in favour of CPR.’ However, we would wish to emphasise that ‘…an initial presumption in favour of CPR’ …does not mean indiscriminate application of CPR that is of no benefit and not in a person’s best interests. The guidance states also in section 8: ‘…there will be cases where healthcare professionals discover patients with features of irreversible death – for example, rigor mortis. In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies.’
Health professionals have a duty to provide care based on the best available evidence or best practice and to recognise and work within the limits of their competence. Whilst death can be certified only by a registered doctor with a licence to practise or by a coroner, death may be confirmed by other health professionals, including paramedics and nurses. Nurses working in an environment in which they may encounter death or cardiac arrest should ensure that they have the necessary competence to recognise when CPR may be beneficial in restoring a person to a duration and quality of life that they would value and when, realistically, CPR would be of no benefit to the person and would deprive them of a dignified death or could potentially do them harm.
Furthermore, we believe that health and care provider organisations have a duty to ensure that they have in place policies and procedures that:
- protect their residents/clients/patients by ensuring that their wishes are known and respected
- protect their staff from a perceived obligation to attempt CPR on people who may not have wanted it but had been offered no chance to discuss their wishes, people who have died and whose death is irreversible, or people who have no realistic prospect of benefit
- provide their staff with appropriate education and training:
- to enable them to discuss with people their wishes for their future care
- on the guidance about decisions relating to CPR and the responsibilities of nursing staff.
We urge regulatory bodies to consider any similar event with regard to its individual circumstances and, when doing so, to take the national guidance into consideration.