In the Midst of Life

this is less confusing.
CPR should not be offered when it is deemed to be futile.
Involve the multidisciplinary team in discussions about end of life.
If your place of work does not have a Do Not Attempt Resuscitation (DNAR) policy, it is important to highlight this. All staff should also be aware of the BMA
et al
(2007) resuscitation guidelines. The National Council for Palliative Care (2002b) has published a document that offers guidance on how to write a local DNAR policy. If you work for an NHS trust, always consult your local policy and guidelines group.
If there is a chance of successful CPR, then the intervention should be discussed with the patient. If the patient does not have capacity, then evidence of advance care planning, either written or verbal, should be sought. If there is no evidence of either, the patient’s representatives should be asked what they think the patient would want. Alternatively, an independent mental capacity adviser (IMCA) or a court of protection decision may be required.
If CPR isnot going to be successful, it should not be offered. The aims of care should be discussed with the patient.
    Implications for practice
    I would argue that nurses are not equipped through basic training to deal with the stress and psychological trauma that patients and family carers are dealing with at the end of life. Nurses develop these skills through experience, reflection and self-awareness. Nurses can support those who are at the end of life by:
Refining their communications skills
Offering appropriate interventions
Checking the patient understands what is happening
Using appropriate terminology.
    Good communication skills
    Good communication includes active listening – this is hearing what is said as well as paying attention to what is communicated in non-verbal ways such as body language.
    It is not possible to guess how someone will feel about CPR as there are huge discrepancies between what we think patients want and what they actually want (Jevon, 1999).
    We need to make sure that patients and families understand that saying no to CPR does not mean they are saying no to all interventions.
    Offering appropriate interventions
    Treatment interventions that are unlikely to be successful should not be offered.
    The CPR guidelines state that each resuscitation decision should be discussed, where appropriate, with the individual or their representative (BMA
et al,
2007). However, ‘discussion’ does not necessarily mean asking the patient or family to make a decision. Discussion may involve talking things over, finding out what the person’s understanding of the current situation is, and outlining the treatment aims (Bass, 2006). This can be achieved by asking the question, ‘What is your understanding of what has been happeningto you/your relative up to now?’ Alternative questions such as ‘Are you the sort of person who likes to know what is going on?’ can be helpful.
    These questions may show that the patient understands much more than first thought, or that they would rather you discussed interventions with someone else, for example their family or carers.
    Check the patient’s understanding
    Patients may have heard what has been said but have not retained the information. They may have difficulty taking in what has been said either because they cannot believe it, or they do not understand the terminology used. It is important to check a patient’s understanding and provide written information if appropriate to reinforce what has been said.
    Using appropriate terminology
    It may not be appropriate to use the term ‘resuscitation’ when discussing end-of-life care with patients. Simple phrases stating that at the time of death you will not attempt ‘anything heroic’, but will ‘do all we can to make sure you are comfortable’, are extremely useful.
    Conclusion
    By making sure we communicate well, and by using tools such as the GSF, LCPI, DNAR policies and advance care planning documentation, nurses can ensure that they are supporting their patients at the end of life.
    Awareness of when CPR is appropriate and careful assessment and care planning by the multidisciplinary team will ensure that patients are only offered interventions that are beneficial.
    References
    Bass, M. (2008) Resuscitation: knowing whether it is right or wrong.
European Journal of Palliative Care;
15:4,
175-178.
    Bass, M. (2006)
Palliative Care Resuscitation.
Chichester: John Wiley and Sons.
    Bass, M.