In the Midst of Life

that it is a quick intervention that guarantees success without any side-effects (Bass, 2003; Diem
et al,
1996).
    CPR was first used in its present advanced life-support format of chest compressions, ventilation and defibrillation in i960 (Kouwenhoven
et al,
1960). The main problem associated with CPR is identifying when it is appropriate to instigate it as a life-saving measure. The concern is that the decision to proceed is often viewed as the default if a decision about resuscitation has not been made.
    CPR was devised as an emergency intervention for unexpected cardiac or respiratory arrest (Kouwenhoven
et al,
i960) and the majority of healthcare professionals are not aware that the success rates for CPR are very low (Wagg
et al,
1995; Miller
et al,
1993) (see Table 1). Only a small percentage of people will survive to leave hospital following a cardiac or respiratory arrest.
    Ewer
et al
(2001) looked at the success rates of CPR undertaken on patients with cancer. They asked whether patients were expected to have an irreversible cardiac or respiratory arrest. The results showed that, of patients having an unexpected, reversible arrest, there was a 22.2% success rate. However, for those who were expected to have an irreversible arrest and were at the end of life, there was 0% success.
    The effects of inappropriate CPR are often not considered. These include post-resuscitation disease (complications caused by resuscitation itself) (Negovsky and Gurvitch, 1995), an undignified death for the patient, and distress to relatives. Paramedics and resuscitation teams may also become demoralised by repeated failures (Jevon, 1999).
    Table
1 . Success rates for CPR

     
    Factors influencing success of CPR
    The success of CPR is often measured in terms of initial success - the return of heartbeat and breathing, controlled independently by the patient. It is also measured in terms of survival to discharge (see Table 1). The chances of successful CPR are improved if
There is early access to a cardiac arrest team
Basic life support is commenced immediately
Defibrillation is carried out as quickly as possible in cases of ventricular tachycardia or pulseless ventricular fibrillation (Jevon, 2002).
    Other positive factors associated with a successful CPR attempt include:
A non-cancer diagnosis
Cancer without metastases
The patient is not housebound
Good renal function
No known infection
Bloodpressure within normal range
The patient has robust health (Newman, 2002).
    The Gold Standard Framework (GSF) suggests that cancer, organ failure, general frailty and dementia are not associated with success (NHS End of Life Programme, 2007).
    The BMA
et al
(2007) recommended that CPR should not be attempted when patients have indicated before the cardiac arrest that they would refuse it or if the attempt is likely to be futile because of their medical condition.
    Resuscitation decisions
    Discussions about resuscitation at the end of life raise a number of questions.
Are public expectations of healthcare and technology unrealistic?
Do healthcare professionals pursue the possibility of an immediate positive outcome from CPR without considering the long-term consequences of the intervention?
Does inappropriate CPR raise false hope in patients, relatives and staff? (Jevon, 1999)
    Awareness and knowledge of CPR guidance among healthcare professionals is poor (Bass, 2003), with knowledge focusing on local policy rather than research evidence and national guidance.
    In addition, healthcare professionals often fail to recognise when a patient is dying, which can result in difficulty making an appropriate decision about whether to resuscitate in the event of a cardiac or respiratory arrest. The Liverpool Care Pathway (LCP) is a recommended national tool that can assist professionals to make an accurate diagnosis of dying (Ellershaw and Ward, 2003). This diagnosis can help to inform discussion about when to initiate CPR.
    Reducing the inappropriate use of CPR
    The inappropriate use of CPR can be reduced by improvingcommunication between all members of the multidisciplinary team. The End of Life Care Strategy (DH, 2008) gives guidance and outcomes for care at the end of life, including dignity, appropriate care and comfort – appropriate care should include refraining from undertaking inappropriate CPR.
    The Mental Capacity Act 2005 allows patients to make advance care plans and allows them to have choices at the end of life. If they are to support