Cardiopulmonary resuscitation (CPR) for people with cancer
This information is for people with cancer who may be asked to discuss the sensitive issue of cardiopulmonary resuscitation (CPR) with their healthcare team.
This is a guide to help individuals and their family, friends and carers understand more about CPR. It also aims to enable them to make informed decisions about the care and treatment they want to receive.
We hope this information answers your questions. If you have any further questions, you can ask your doctor or nurse at the hospital where you are having treatment.
What is cardiopulmonary resuscitation (CPR)?
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Cardiopulmonary resuscitation (CPR) is a way of trying to restart the heart and breathing once they have stopped. When the heart stops beating, this is known as a cardiac arrest. If the breathing stops, this is called a respiratory arrest. They commonly occur together, and this is known as a cardiopulmonary arrest. Death will result if a cardiopulmonary arrest is not corrected quickly.
A cardiac or respiratory arrest may occur for a number of reasons and is different from a person having a heart attack, which is a particular medical condition.
CPR usually involves pushing down on the chest (chest compressions). Depending on the circumstances, it may include giving rescue breaths into the mouth or giving oxygen into the lungs. Medication is also often given, along with intensive support and monitoring.
CPR is different from other forms of resuscitation doctors might refer to – for example, using intravenous fluids to 'resuscitate' a person who is severely dehydrated.
If a person has a cardiopulmonary arrest in hospital, staff will sound an emergency alarm to alert the healthcare team that there is an emergency situation. An arrest or resuscitation trolley will be taken to the patient. The trolleys contain essential equipment and are available in the main areas of a hospital, as well as on every ward and in every clinic.
A resuscitation team will also be alerted to come to the patient. This includes a team of healthcare professionals, such as doctors and nurses, who are experienced in dealing with emergency situations.
It can be extremely distressing to see CPR being attempted, especially if it’s a loved one who is unwell. Sometimes families will be asked to leave the area, and they will be kept informed of what is happening.
Why would I need to discuss CPR?
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Most people won't experience a cardiopulmonary arrest during a hospital admission. However, your doctors may talk to you about CPR when you are admitted to hospital. This is to ensure that you are included in making the decision about whether or not CPR should be attempted if your heart or breathing stops.
As each situation is unique, the topic of CPR needs to be dealt with sensitively. Doctors will often explain if they feel that CPR is unlikely to be successful, especially when someone may be terminally ill. In these situations, attempting CPR will almost certainly be unsuccessful and will only cause unnecessary distress to both the patient and their loved ones.
You can ask to speak to your doctors about CPR if this is something you’d like to discuss and they’ve not mentioned it at all.
How successful is CPR for a person with cancer?
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CPR is not always beneficial. Its success depends on many factors, including:
the age and general health of the individual
any underlying health problems
the type and extent of the cancer
the main cause of the heart and breathing stopping
how quickly the heart and breathing can be restarted.
There are more than 200 different types of cancer, and many types of cancer treatment that can affect people in very different ways. Some people may have potentially curable cancers, while others may have cancer that can't be cured. Each individual situation is different.
If a cancer is very advanced, the heart and breathing may gradually slow down and stop as part of the natural process of dying. In this situation CPR wouldn't be helpful or appropriate, as it's probable that the cancer itself will have affected some vital organs of the body, causing them to gradually stop working.
Sometimes a cancer may be incurable, but the person may be expected to live with the condition for a long while – sometimes for years. There may be many reasons why the heart or breathing stops suddenly, such as a serious infection caused by treatment. In this situation, attempting CPR may be appropriate, but it may still be unsuccessful.
There are four possible outcomes following cardiopulmonary resuscitation, which are:
Unfortunately, only a small number of people will make a complete recovery and be discharged from hospital.
Some may show a partial recovery but will be left with serious health problems, despite every effort being made to try to help.
For some people survival may be prolonged, often by using an artificial ventilator (breathing machine) in an intensive care unit. While this may extend their life by a matter of hours, days or sometimes weeks, the person's quality of life is usually very poor.
For many, CPR will not be successful and, sadly, they will still die.
Making decisions about whether to attempt CPR
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Ideally, you’ll be able to discuss your views about CPR with your medical team. You’ll be able to say whether you would, or would not, prefer to have CPR if a cardiac or respiratory arrest occurs. However, it's important to remember that in most situations, and particularly when a cancer is very advanced, CPR is not often successful. Doctors will tell you if they feel there’s little chance of CPR working in your situation.
If there has not been any discussion about CPR between a person and their medical team, and their heart or breathing suddenly stops, the decision about whether or not to attempt CPR is made on medical grounds.
If a person states that they don't want CPR to be attempted, their decision is final. The medical team can only override the decision of the person in very rare circumstances, where the individual is considered not to be of 'sound mind' – for example, if they have a serious mental illness or are confused or disorientated.
Thinking about and discussing CPR can be very difficult. You may want to talk things over with your medical team, specialist nurses, or spiritual carers such as your chaplain or priest.
Some people feel they can't make the decision themselves and may want their doctor to make it for them.
Can I insist that CPR is attempted?
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You can certainly express your views about CPR and request that it will or will not be attempted.
If your doctor feels that it’s unlikely to be successful and doesn't believe that CPR should be attempted, you can arrange for a second medical opinion from another senior doctor. Your doctor or GP can advise you about seeking a second opinion.
The healthcare team will take your wishes about CPR into account. However, a senior doctor can ultimately decide not to attempt CPR if in their clinical judgement it's not appropriate.
What if I am unable to make this decision?
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In some situations, you may not be able to make a decision about CPR – for example, if you’re unconscious or too drowsy from medication.
In this situation, doctors would usually discuss CPR with your next of kin or other appropriate relatives. They would try to get an idea about your probable views on CPR from people who know you. Normally, you would need to give your permission before medical staff can discuss any details regarding your medical condition with your family.
In England, Wales and Northern Ireland, although relatives can give their view, any final decision about CPR would be the responsibility of the doctor when the patient is unable to make the decision.
In Scotland, anyone over the age of 16 is allowed to nominate a proxy decision-maker, should they become unable to make the decision themselves. The nominated person must be consulted about treatment decisions, but they can't demand treatment that the doctors feel is unreasonable.
Once the decision has been made
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The doctor will inform other members of the healthcare team that CPR has been discussed with you and what decision has been made. This information is confidential and will only be discussed among those caring for you, such as the doctors and the nursing team.
The decision will also be written clearly in your medical and nursing notes, but it will not be documented in the nursing notes at the end of your bed.
If the decision has been made not to attempt CPR, this is written as a 'do not attempt resuscitation' (DNAR) order, or as 'not for resuscitation' (NFCPR). In the medical notes, the doctors will usually document a planned review date, so that this issue is reviewed on a regular basis.
What if a cardiac or respiratory arrest happens when I'm not on the hospital ward?
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If a person leaves the hospital ward, for example for an x-ray, they’ll usually take their medical notes with them. Many hospitals have a system whereby a sticker on the outside of the medical notes indicates that CPR should not be attempted. This is to ensure that all healthcare professionals are aware of the person's 'resuscitation status'.
As well as the sticker system, hospitals aim to have good communication so that staff in other departments are aware if CPR is not to be attempted. This covers the situation where a person leaves the ward but doesn't have their notes with them.
What happens when I'm at home?
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A person may wish to discuss their concerns about CPR before they are discharged from hospital. It's important to bear in mind that in the community there is no specialist team or equipment at hand should a cardiopulmonary arrest happen. In that situation, a 999 call would be made.
Many GPs and community palliative care teams will routinely discuss CPR with their patients and families, especially if your condition begins to change or worsen. Any decision you make about whether or not you would like CPR to be attempted will be communicated to all the relevant members of your community team, including your local out-of-hours service and the ambulance service. This can help prevent unwanted attempts at CPR, which can be very distressing.
Whoever discusses CPR with you should tell you how your decision will be communicated to the people who need to know. You can also ask for a copy of the documentation, for your family or carers to have at home.
If it has been decided that CPR shouldn't be tried for a person and an ambulance is called, the ambulance crew will always attempt CPR unless there’s clear documentation stating the 'do not attempt resuscitation' order.
What happens if I change my mind?
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You are free at any time to change your mind about whether or not CPR should be attempted. If you do change your mind, it’s important to tell a member of your healthcare team and discuss it with them. They will discuss their views on your changed decision with you. If they agree with your changed decision about CPR, they’ll make sure it is recorded in your medical notes. Remember to also tell your family or carer, as this will help to avoid any confusion.
An advance decision to refuse treatment (previously known as a living will)
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Some people with cancer may wish to make a choice about whether they want CPR to be attempted in the months or years ahead. If they choose not to have CPR attempted, they can record this using an advanced decision to refuse treatment document (known as an advance decision or advance directive in Scotland). This means that, should the situation ever arise, healthcare professionals and family and friends will know what the person’s wishes are. A copy of the advance decision to refuse treatment can be put into the person's medical notes.
You can ask your specialist nurse or doctor for more information about this.
Will my decision affect the rest of my treatment or care?
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Any decision you make about CPR will not affect any other care or treatment that you receive.
Each time you’re admitted to hospital, one of the doctors involved in your care will review your CPR status and discuss it with you. This is necessary because your medical condition and views may change.
Take time when considering the issue of CPR, and ask your medical team if you are unsure about anything. It may help to ask your family and friends for their opinions, as well as writing down a list of questions to discuss with your doctor, before making your decision.
This section has been compiled using information from a number of reliable sources including:
Decisions Relating to Cardiopulmonary Resuscitation. 2007. A Joint Statement from the British Medical Association, Resuscitation Council (UK) and the Royal College of Nursing.
Resuscitation Council (UK) Resuscitation Guidelines 2010. www.resus.org.uk (accessed August 2012).
With thanks to Pauline McCulloch, Clinical Nurse Specialist.
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