Resuscitation and Treatment Plans
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There are various different types of resuscitation and treatment plans, made in advance to direct what emergency (or other) treatment should be provided under certain circumstances. Some plans cover resuscitation only, others cover resuscitation and other forms of emergency treatment, others cover all aspects of treatment and care. Some of these are completed by a doctor in consultation with the patient (or the loved ones of someone with dementia), and some are completed by the patient to express their wishes. The names used for each type of plan vary from country to country, as do their their legal statuses.
We suggest you keep a signed copy of all resuscitation and treatment plans in a hospital bag for your loved one, in case they have to go to hospital, with a second copy in a bag for the things you'd need when supporting them.
Resuscitation plan (DNACPR / DNR / DNAR)
The most commonly used plan relates to cardiopulmonary resuscitation (CPR), and reflects that for any patient who needs CPR (i.e. their heart has stopped beating and/or they've stopped breathing) there's approximately a one or two in ten chance of CPR working. Additionally, whilst the patient may live they may have reduced brain function, amongst other issues. Furthermore, for elderly patients with medical conditions the chances of survival are lower still.
It's important that a decision made in relation to CPR is not taken as a decision in relation to any other form of medical treatment (emergency or not), as the decision takes account of the specific chances of CPR working, the likely outcome even in the case of survival, and the potential distress of the treatment. To reduce the chance of a CPR plan being applied more broadly than intended, additional forms of plan have been developed, as described in the next subsection.
In view of the low chances of success, and the distress that CPR may cause to the patient in what's likely to be their last moments (and the distress to their loved ones), a decision may be made in advance of such an event as a guideline for what's appropriate in the best interests of the patient - i.e. whether not to conduct CPR. This decision may be made in advance by someone who's sufficiently mentally competent to understand the issues (although this doesn't necessarily preclude early stages of dementia if it's assessed they're still capable of understanding - you should seek advice), or else may be made by a qualified doctor. A doctor making the decision will take account of health conditions and must discuss the person's wishes - for someone who has dementia this discussion should be with their loved ones. In the UK, if the person has given power of attorney to someone, this power may specifically cover making decisions on life-sustaining treatment on their behalf.
The absence of an advance decision or resuscitation plan does not mean that CPR is inevitable: medical staff will still need to make a decision as to whether it's appropriate to attempt it.
Further information on the situation with DNACPR plans in the UK is given on the NHS website Health A-Z for 'do not attempt cardiopulmonary resuscitation'.
For information on the situation in other countries, where terms such as Do Not Resuscitate (DNR) or Do Not Attempt Resuscitation (DNAR) are used, see the Wikipedia website, for 'do not resuscitate'.
Formal plan for emergency care and treatment
Recognising that resuscitation plans cover only one limited aspect of treatment and care, and that there's the potential for a resuscitation plan to be misinterpreted and misused in relation to other aspects of treatment and care, various other forms of plan are being developed.
This subsection covers formal plans that are prepared by a doctor in consultation with the patient, in the same way that resuscitation plans are, but which cover a wider range of treatments. Informal plans are covered in the next subsection, and can be used where formal plans aren't available, or don't cover all aspects of treatment and care, or don't go into sufficient detail.
In the UK
ReSPECT plans (Recommended Summary Plan for Emergency Care and Treatment) are currently being rolled out, although not all areas are using them yet. More information is given on the Resuscitation Council UK website, under ReSPECT - for Patients and Carers.
In the US
POLST plans (Physician Orders for Life-Sustaining Treatment) are currently being rolled out in most states. More information is given on the Wikipedia website, for 'POLST'.
Informal plan for care and treatment
An informal plan can be made, to cover wishes regarding resuscitation (see above), other emergency life-sustaining treatments, and also other treatment and care. It can be useful where a formal plan system (see the previous subsections) isn't available, or doesn't cover all aspects of treatment and care, or doesn't go into sufficient detail. An informal plan acts as a guideline that should be considered by those giving medical care, but isn't binding on the medical profession.
It's a good idea to have one, and of course it's important to make sure the relevant people know what's in it. Keep a record of everyone who has a copy, in case you later want to replace it with a revised version. The plan should include emergency contact numbers for the person's loved ones.
In the UK the plan is called an Advance Statement, with the term Advance Care Planning being used in England, Wales and Northern Ireland, and the term Anticipatory Care Planning in Scotland.
More information on advance statements and how to prepare one is given in the following sources from the UK, and these principles will be useful elsewhere:
- the NHS website guide to advance statements
- the Age UK website advance decisions factsheet
- the Macmillan Cancer Support website, for 'advance or anticipatory care planning'
Although an advance statement isn't binding, if you're indicating a preference to avoid life-sustaining treatment and you have a life insurance policy then you may need to discuss this with your insurer.
Advance Decision / Directive ('Living Will')
A decision to refuse resuscitation (CPR), or other forms of life-sustaining treatment such as ventilation, may be made in advance by someone sufficiently mentally competent to understand the issues. For it to be legally binding it must be prepared correctly and signed. In the UK, if the person has given power of attorney to someone, this power may specifically cover making decisions on life-sustaining treatment on their behalf.
It's important to make sure the relevant people have a signed copy. Keep a record of everyone who has a copy, in case you later want to replace it with a revised version.
If your decision is to refuse life-sustaining treatment and you have a life insurance policy then you may need to discuss this with your insurer.
In the UK, the term Advance Decision to Refuse Treatment is used in England and Wales, the term Advance Directive is used in Scotland, and the term Advance Decision to Treatment is used in Northern Ireland.
More information on advance decisions / directives and how to prepare one is given in the following sources from the UK:
- the NHS website information on advance decisions
- the Age UK website's advance decisions factsheet
- the Macmillan Cancer Support website, for 'advance or anticipatory care planning'
For information on the situation in other countries, where terms such as Advance Healthcare Directive are used, see the Wikipedia website, for 'advance healthcare directive'.