CPR / DNR / TEP / Life Sustaining Treatment
The issue of death and dying is by the very nature of it, highly emotive. These all interchangeable terms for non-medical professionals, but they are each a distinct medical term.
CPR is Cardiopulmonary Resuscitation, which lay people should understand as chest compressions. It is performed when someone’s heart has stopped. DNR, is the term used when a decision is made not to perform resuscitation (CPR), it does not include other forms of refusal of treatment. In the UK, when making end of life decisions, the NHS complete a Treatment Escalation Plan (TEP), which includes the question about whether CPR should be performed, but covers more issues than just that. Life Sustaining Treatment is any form of care or treatment that sustains life, which will vary from case to case, but could include food and fluid or anti-biotics, amongst other things.
The next key issue to understand about CPR on a very elderly and frail person, is that it is highly unlikely to be offered by the doctors and cannot be insisted upon. In the UK, our key right in respect of healthcare, is the right to refuse. There are some limited rights of treatment, but generally the offer of treatment is a clinical decision. Which means that the doctor is only going to offer medications or treatments that they consider to be clinically appropriate. Once offered, the person has the right to refuse. They do not have the right to demand the treatment, although a person can ask. CPR is not generally offered to elderly frail people because the outcome would be very poor. It is not like the movies!
When CPR is performed, if the person survives, they are then likely to spend the next couple of weeks in intensive care on a ventilator. If they are elderly, the person’s ribs are likely to have been broken in the process. The most likely outcome is that they would die within the next few days. However if they did survive, they would be very much more unwell than before the CPR was performed, to the extent that they could be vegetative. If not vegetative, then they will still be very much more unwell than they were before. So because the outcomes are all really negative, it is not offered.
When doctors complete a TEP, they expect the answer to DNR, the refusal of CPR to be no, but when they are told that the person still wants this, they then have the difficult job of explaining the outcomes and why they are not really offering it. In seeming to offer it, they are just helping the family member comes to terms with the impending end of life of their loved one. This conversation should always be sensitively managed, but sadly isn’t always done so.
In the UK, the conversation should take place with the GP or other healthcare professional and the person and/or their family about the person’s wishes for the end of life. This will then prompt the completion of the TEP. The TEP can be changed and as someone gets frailer, it often is reviewed and earlier options that were included are removed. A commonly changed answer is the issue of whether a person should be admitted into hospital. When someone is just beginning to become more frail, but still has a really good quality of life, this would be answered in the positive, they should go to hospital. Over the next few months and years, as that person becomes increasingly frail and their quality of life diminishes, this question might change, when a new TEP is completed.
When people say that they are DNR, if they are lay people, it remains unclear whether the refusal is intended to be limited to only CPR or a wider refusal of care and treatment.
End of life discussions can be very difficult and in times of stress, which is the time that these discussions often take place, they can be even more tricky. Compassion and kindness is the answer to making this difficult time a little bit easier.