Cardiopulmonary resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is a way of trying to restart a person’s heart and breathing if they have stopped suddenly.
When the heart stops beating suddenly, this is called a cardiac arrest. If the breathing stops, this is called a respiratory arrest. Usually, both happen at the same time. This is called a cardiopulmonary arrest. If someone having a cardiopulmonary arrest does not have their heart and breathing restarted quickly, they will die.
A person’s heart or breathing can stop for different reasons. For example, a heart attack can make the heart stop.
How CPR is given
CPR involves different treatments to help restart a person’s heart or breathing. The first treatment usually involves repeatedly pressing down on the person’s chest to help the heart pump blood around the body. This is called a chest compression. CPR may also include blowing air into the person’s mouth to push oxygen into their lungs. Unfortunately, these procedures can also cause injury, especially to someone who is frail or very ill. This can include broken ribs.
If CPR is given at home or in a public place, it may be the only treatment until an ambulance arrives.
If CPR is given in hospital, the doctors or nurses will also use other treatments. They may give drugs and use specialist equipment to give oxygen. They will use a machine called a defibrillator to monitor any heartbeat. They can also use the defibrillator to give shocks to start the heart again.
Some public places, such as airports or shopping centres, may have a portable defibrillator. This can be used to try to restart the heart. No specialised training is needed to use this, so anyone can do it.
A cardiopulmonary arrest is an emergency medical situation. It can be frightening. It can be distressing to see someone being given CPR, especially if they are a loved one. The healthcare team involved will give support and information to any family or friends when they can. They may ask them to leave the area while they are giving CPR. But some people choose to stay with their loved one.
Only a small number of people recover after having CPR. Some people recover, but are left with serious long-term health problems. For others, CPR restarts the heart and breathing, but they are too unwell to recover. They may need ongoing medical support, such as a breathing machine (artificial ventilator) in an intensive care unit. They may continue to live for hours, days or sometimes weeks, but cannot survive without this support.
For many people, CPR does not restart the heart or breathing. Sadly, they die despite the treatment.
Whether CPR works can depend on:
- the age and general health of the person
- any other health problems
- the reason the heart and breathing stopped
- how quickly the heart and breathing can be restarted.
For people affected by cancer, the success of CPR may also depend on the type and stage of the cancer, and any cancer treatment they are having. There are many types of cancer and cancer treatment. Some people will have treatment that aims to cure the cancer. Others may have cancer that cannot be cured. Sometimes treatment itself may cause problems with the heart or breathing.
If a cancer is very advanced, the heart and breathing may gradually slow down and stop. This is part of the natural process of dying. In this situation, giving CPR is very unlikely to restart the heart. CPR may make the dying process longer and more distressing. It may also be more distressing for family and carers.
Your doctor or nurse may talk to you about CPR. They will talk about:
- what is involved
- the possible risks and benefits
- whether CPR might work in your situation.
If CPR is unlikely to be successful, they will explain why this is.
They may talk to you about what the best treatment is likely to be if your heart or breathing stops. This can be hard and upsetting to talk about. But it is important you are included in the decision about whether or not CPR should be given.
If your doctor or nurse has not talked to you about CPR but you want to, you can speak to them about it. You may also want to talk about it with other people, such as a partner, family member or religious adviser.
Your healthcare team should involve you as much as possible when making a decision about CPR. You may need time to think carefully about your situation. Think about what would be best for you if your heart and breathing stopped. Your team will consider your wishes about CPR. But the final decision will be made by a senior doctor. They will think about the benefits and risks of CPR for you.
They will tell other members of the team that you have talked about CPR and what decision has been made. This information is confidential. It will only be shared with the team caring for you.
If you have told your healthcare team you do not want CPR, they will accept your decision.
You may decide you want CPR, even if your healthcare team tells you it is unlikely to work. If you do not agree with your team’s advice, you can ask for a second opinion from another senior doctor. It is important to be aware that another doctor may have the same opinion as your healthcare team.
Sometimes, the healthcare team may decide the person is not able to make the decision about CPR themselves. For example, this may happen if someone has a serious mental health illness, or is confused.
Some people do not want to make their own decision about CPR. You do not have to talk about CPR with anyone or decide about CPR if you would prefer not to. Instead, you can let your healthcare team decide for you.
Recording a decision
The decision about CPR will be written clearly in your medical and nursing notes. If the decision has been made not to give CPR, this is written as a 'do not attempt resuscitation' (DNAR) order or 'not for cardiopulmonary resuscitation' (NFCPR). The doctor usually also writes a date to review the decision in the medical notes. This means the decision will be discussed again, to check it is still correct and up to date. For people with advanced cancer, the doctor may write that the decision is indefinite. This means it does not need to be reviewed.
If you are in hospital, the decision will be written in your medical and nursing notes. But it will not be in any notes next to your bed. If you leave the hospital ward, for example for a scan, your medical notes usually go with you. Many hospitals use stickers on the outside of medical notes to show that CPR should not be given. This helps anyone looking after you find this information quickly. Your team will also aim to communicate clearly with staff in other departments. Anyone involved in your hospital care should know about a CPR decision.
If you go home from hospital, the community healthcare team looking after you should also be told about a CPR decision. This includes:
- your GP
- your local out-of-hours service
- the ambulance service.
It may also include:
- the community palliative care team
- district nurses
- any carers.
If there is a DNAR or NFCPR decision, sometimes it is written on a form you can take home with you. If you are being cared for at home, check if the community healthcare team will accept the form. You need to keep it in a safe place at home.
GPs or community palliative care teams usually talk about CPR with the people they are looking after. But if they have not and you would like to, ask to talk to them.
If no decision has been made
If your heart or breathing stops, your healthcare team will make the best decision they can at the time if:
- you have not already made a decision
- it is not clear what the decision is.
They will decide whether to give CPR based on your medical situation. If your heart or breathing stops at home and an ambulance is called, the paramedics will always give CPR. This is unless there is a clearly written DNAR or NFCPR order.
In some situations, you may not be able to make a decision about CPR. For example, this might be if you are unconscious or too drowsy from medication.
If this happens, your healthcare team will make any final decision about CPR. They will think about your medical situation carefully. They will also talk to people close to you, such as your next of kin or family. This is because these people may be able to suggest what decision you would make.
If you have asked your healthcare team not to talk about your care with certain people, they will respect this. They will not talk about the CPR decision with those people.
You may have arranged for someone to help make decisions for you if you are unable to:
- In England and Wales, this person is called a health and welfare attorney. They must be named in a legal document called a lasting power of attorney (LPA).
- In Scotland, this person is called a welfare attorney. They must be named in a legal document called a power of attorney (PoA).
Your healthcare team must talk to your attorney about any decision about CPR. But if the healthcare team decides giving CPR will do you more harm than good, your attorney cannot demand treatment.
In Northern Ireland, attorneys do not make decisions about medical treatment. But your next of kin or family should still be asked for advice about the decision.
A written statement of your wishes to refuse a particular treatment in a specific situation is called:
- an Advance Decision to Refuse Treatment (ADRT) in England and Wales and in Northern Ireland
- an Advance Directive (AD) in Scotland.
It is a way of making sure everyone knows in advance if there is a treatment you do not want to have.
Before making an ADRT or AD, it is important to talk about it with a healthcare professional. This may be your GP, or a doctor or specialist nurse looking after you at the hospital. They can tell you what might happen if you stop a particular treatment or decide not to have it. They will also make sure your written statement meets legal requirements.
If you decide you do not want to be given CPR, you can record this in your written statement. A copy can then go into your medical notes for your healthcare team.
A decision about CPR will not affect any other care or treatment you get.
Each time you are admitted to hospital, a doctor will check the CPR decision and talk to you about it. This is important, because your medical condition or decision may change.
You may change your mind and want to review your decision. You will need to talk to your healthcare team about this. If the decision changes after you talk about it, your doctor will record it in your medical notes. Remember to tell your family or carer about any changes to avoid confusion.
Talk CPR has more information about CPR.