In June 2006, Dr M Harkness and Dr P Wanklyn had published a prospective audit assessing the prevalence and documentation relating to CPR decisions in the Leeds General Infirmary, for patients aged over 65 years. The study is outlined below. For copyright reasons, this has been done very sketchily but we hope it will be useful to health professionals and encourage them to read the full paper.

In their introduction, Drs Harkness and Wanklyn identify the fact that while many patients will have preferences relating to CPR, many may not volunteer this information and their views may not be taken into account unless there are specific opportunities to discuss the subject.

Do not attempt resuscitation orders are widespread in clinical practice, to cater for situations where the patient forgoes potential life-prolonging CPR. Where no decision has been made beforehand, the default response is to do CPR.

To help the patient make an informed decision regarding CPR, the physician needs to assess capacity which, the authors break down into the components of the ability to understand information; the ability to retain information; the ability to process information and the ability to express a clear opinion based on that information. They hasten to point out that while a patient may be able to understand and make decisions regarding trivial issues e.g. what to have for breakfast, this capacity cannot necessarily be generalised to more important issues such as CPR.

Where the patient lacks capacity, it falls to the multi-disciplinary team to discuss CPR and, where possible to involve the family in these discussions.

In the Leeds Teaching Hospitals, the policy for CPR decision making includes a resuscitation status form filed in front of the hospital cast notes where it is accessible to all staff caring for the patient. Applying to CPR only, it calls for information regarding the resuscitation status (Do not or do attempt resuscitation); duration of the status; review date; who the decisions were discussed with (patients, named relatives); who discussed the details (named health professionals); discussions limitations; professional communication of the CPR status; etc.

The authors compared their practice with those of other physicians. The key findings were:

• A CPR decision was available in only around 1/3 of the cases and was documented on the resuscitation form in slightly less than that. 25% of the status forms did not have a signature and of those that did, all but one had been signed by a registrar or consultant. Over 80% of the documented decisions were indefinite.
• There was marked variability between consultant teams as to how often CPR decisions were made.

The authors conclude that:

• clinicians should be more pro-active in assessing patients for whom CPR has little to offer.
• while there is some improvement in documentation of CPR decisions, but this needs to be improved further and the quality of the documentation also needs improvement.
• despite increased levels of documention, discussions with patients remain in the minority.
• geriatricians are more likely than other specialists to make CPR decisions.
• doctors often disagree about CPR decisions, fearing that discussing the issue with patients may cause distress. The authors cite studies which show that these fears are largely unfounded.
• nurses play a central role in discussing CPR with patients. Part of the counselling process involves making the patient aware of the success rate of CPR, since patients tend to overestimate the success rate. Information leaflets for patients and families are a useful tool in this regard.
• the authors performed a pilot study to survey attitudes of patients and families about information leaflets on CPR. The leaflets have been well received.

The leaflet, written at a level appropriate for patient and family, includes:

• What is CPR?
• What are its chances of success?
• The side effects of CPR (e.g. pain in the chest, bruising, fractured ribs and, in many cases, a degree of brain damage).
• The issues in deciding whether to implement CPR or not.
• An invitation to discuss CPR with any member of the team ("CPR is a very sensitive subject, so we would very much appreciate it if you would open the discussion with us. We can then talk about the options and deal with any worries you may have.")