1. RC (UK) O1 ETHICS AND LEGAL ASPECTS OF RESUSCITATION

2. RC (UK) O2 Objectives To understand: The ethical and legal implications of the duty of care in regard to resuscitation The implications of ‘Do Not Attempt Resuscitation’ orders and ‘Advanced Directives’ The involvement of relatives in witnessing resuscitation attempts The considerations involved in the decision to stop a resuscitation attempt

3. RC (UK) O3 Failure to start resuscitation Failure to recognise cardiac arrest has occurred Rescuer inadequacy Real or perceived risk to rescuer from attempting resuscitation

4. RC (UK) O4 CPR should be commenced routinely unless: The patient’s condition indicates that successful resuscitation is unlikely to result in length or quality of life acceptable to the patient It is not in accord with the recorded, sustained wishes of a mentally competent patient

5. RC (UK) O5 The overall responsibility for the decision to perform resuscitation rests with the senior clinician in charge of the patient’s care.

6. RC (UK) O6 The appropriateness of resuscitation may be raised by: The patient Relatives or close friends General Practitioner Medical staff Nursing staff

7. RC (UK) O7 Do Not Attempt Resuscitation (DNAR) Policy Regularly reviewed and recorded in: Medical notes Nursing notes Where possible must include prior consent of patient, explanation and justification.

8. RC (UK) O8 DNAR Orders apply to resuscitation only

9. RC (UK) O9 Deciding when to stop Place People Time

10. RC (UK) O10 Prolonged resuscitation Indicated in special circumstances: Hypothermia Near drowning Drug overdose Children

11. RC (UK) O11 Advance Directives Refusing CPR can be legally binding if certain safeguards are met and doctor is satisfied that request is genuine May be difficult in emergencies If in any doubt - Resuscitate

12. RC (UK) O12 Advanced Directives Safeguards: Adult Patient mentally competent when decision made Circumstances foreseen Not under duress Patient aware of the implications

13. RC (UK) O13 Should relatives witness resuscitation? May help in bereavement process Exclusion may be distressing Must be accompanied by appropriate person Team aware Patient takes priority Staff stress and training recognised

14. RC (UK) O14 Any Questions?

15. RC (UK) O15 Summary It is important to commence resuscitation promptly and effectively To know when such measures are contraindicated To know when resuscitation attempts should cease

16. RC (UK) O16 A colleague states that she doesn’t want to be resuscitated if she ever has a cardiac arrest. The next week she sustains a cardiac arrest in front of you. –Do you start resuscitation? You find out that she was diagnosed last week with cancer and is taking anti-depressants. –Do you continue resuscitation? Her partner arrives and asks you to reverse your decision –What do you do?

17. RC (UK) O17 An 82 year old woman falls and sustains a fractured neck of femur. She lives in sheltered housing, is prone to forgetfulness, and has been unwell for the last 2 days. A resuscitation decision needs to be made. –Who should be involved with this decision? –What makes a ‘DNAR’ order valid?

18. RC (UK) O18 It is 3 am and 54 year old Albert Jones is recovering from a routine hernia operation when he collapses, is unsuccessfully resuscitated, and dies. –How do you contact the relatives who live an hour away? –How do you receive them as they arrive on the ward? –Who should discuss the collapse with them and how?

19. RC (UK) O19 In the A&E department, a 42 year old man is brought in by his wife suffering from a suspected MI. They are in the cubicle together when he collapses in VF –What do you do with his wife? –She wants to stay – what support do you offer her? –Should relatives be present during resuscitation?

20. RC (UK) O20 A 48 year old man collapses in a public place as you are driving past. –Would you stop to assist? –Would you start resuscitation if needed? –What is the legal and professional view in this situation? The Ambulance Service arrive and, on monitoring, he is found to be asystolic and remains in this rhythm. –When do you decide to stop?

21. RC (UK) O21 Your elderly next door neighbour has not been seen out today. You find him on the floor, collapsed, not breathing, but with a weak pulse. There are a number of empty drug and brandy bottles around him. Pinned to his chest is a note saying “DO NOT RESUSCITATE” –What do you do?