Why it matters
Ambulance clinicians often have to make decisions about whether to attempt cardiopulmonary resuscitation (CPR) when they attend a call and find a patient whose heart has stopped.
UK professional guidance recommends: ‘Where no explicit decision about CPR has been considered and recorded in advance, there should be an initial presumption in favour of CPR.’ Clinicians are, however, given the discretion to make decisions not to attempt CPR where they think it would be futile, ‘for example, for a person in the advanced stages of a terminal illness where death is imminent and unavoidable.’
However, there is no explicit mention of the importance of listening to family members’ views of what the patient would want, and no reference to the legal obligation of the ambulance clinician to follow the Mental Capacity Act 2005 and do what is in the patient’s best interests.
Approach
To highlight the moral discomfort experienced by ambulance clinicians, and the ethical and legal challenges they face, we collaborated with an ambulance clinician and a bereaved relative to understand their perspectives, reviewed the legal and ethical framework under which they are operating, and suggested changes to policy and guidance.
What we found
To highlight the issues, an ambulance clinician outlined a case study about a patient who had gone into cardiac arrest. This demonstrated the grey area faced by clinicians when they need to make a ‘best interests’ decision. The call for emergency help was to manage a seizure and not to provide resuscitation.
A family carer articulated his perspective: in his view end-of-life guidance, protocols, mindsets, and laws require urgent improvement. The experience of the family member in a CPR situation demonstrated that the CPR guidance “protects professionals at the expense of damaging relatives and, sometimes, even patients.”
We outlined the legal position. The Mental Capacity Act governs the decision-making of ambulance clinicians, in that they must ascertain whether the patient has the capacity to make their own decision to consent or refuse CPR. If the patient is unable to make this decision at that point in time, then a ‘best interests’ decision must be made. The process for doing this is set out in the Mental Capacity Act: those close to them, including friends and relatives, must be consulted, and the patient’s wishes, feelings, beliefs, or values must be ascertained, in order to make a decision which is closely aligned to what that individual would have wanted.
We made three recommendations:
- Individuals should be encouraged to discuss and document their wishes, for example on a ReSPECT plan (https://www.resus.org.uk/respect). This removes some of the moral and decision-making burden from families and healthcare professionals.
- Professional guidance could be improved to guide clinicians about what to do in situations where no documentation about patient preferences exists, and where CPR is highly likely to be futile and might cause harm. With improved guidance, clinicians would not feel they are having to choose between what they consider morally right and what they must do to protect their professional registration. Guidance and training should emphasise teamwork between the clinician and the family/carer, and the default assumption should be that clinicians and relatives have a shared goal of what is best for the patient.
- Families should be better supported to understand what may happen when a loved one dies at home, and which services are available to help, so that they are better equipped to deal with the crisis.
