Page 695 - ACCCN's Critical Care Nursing

672 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

relatives, out-of-body sensations, feelings of presence of and outcomes after CPR strongly influences their prefer-
deity and peace. 120,121 These experiences may vary between ences. 129 Most patients, and indeed healthcare workers,
131
cultures: Euro-Americans may report a golden colour commonly hold unrealistic expectations of CPR success,
light where as Tibetans may report a clear light. 122 People and will often reverse their preference for commencing
report the experiences as pleasant, and they have resulted CPR once they are informed of the true probability
in positive life changes for the individual. After-effects of of survival and functional status after resuscitation. 129
an NDE include absence of fear of death, more spiritual Regardless of this, healthcare workers continue to dem-
view of life, less regard for material wealth and/or a onstrate a reluctance to discuss CPR options with patients.
heightened chemical sensitivity. 119,120 The incidence of Despite open discussion, poor documentation and com-
NDEs after cardiac arrest is reported at 6–18%, 118,123 with munication can result in CPR being inappropriately
the frequency generally being higher in people under 60 commenced. 132 Approximately one-third of patients suc-
119
years of age. Hence, an awareness of the incidence of cessfully resuscitated have subsequently stated that they
133
NDEs, the cultural differences and needs of the person did not want to be resuscitated. Conversely, and con-
with a reported NDE are essential postcardiac arrest. 120,124 trary to medical and nursing opinions, some people
choose CPR even when they have a terminal illness, coma
LEGAL AND ETHICAL or serious disability. 129
CONSIDERATIONS Standardised orders for limitations on life-sustaining
treatments (e.g. DNAR, POLST) should be considered
Burgeoning technology in the 1960s enabled the support to decrease the incidence of futile resuscitation attempts
of oxygenation and circulation for people whose illnesses and to ensure that adult patient’s wishes are honoured.
would have been lethal just a few years before. Enthusi- These orders should be specific, detailed, transferable
asm for restoration of life led healthcare workers to rou- across healthcare settings, and easily understood. Pro-
tinely initiate CPR for all patients who died in hospital. 125 cesses, protocols and systems should be developed that
Unfortunately, this led to inappropriate resuscitation fit within local cultural norms and legal limitations
attempts and the realisation of the economic, medical to allow providers to honour patient’s wishes about
and ethical burden to society when survivors had a resul- resuscitation efforts. With the exception of a zero sur-
24
tant poor quality of life. 126 In the 1970s, growing concern vival rate there remains no formal consensus on DNAR
about inappropriate application of CPR and patient’s decision-making practices or the termination of resuscit-
rights led authors to suggest means of forgoing resuscita- tion. While researchers have attempted to develop prog-
127
tion and involving patients in decision making. Tradi- nostic indicators for cardiac arrest outcome, moralists
tionally, the decision to initiate or withhold CPR was would argue that the use of such prognostic tools alone
often made by the treating medical team in the absence reflect utilitarianism, 133 and should never be used in
of the patient or family. 128
isolation of the input of the patient and healthcare
Hospitals responded by developing procedures for with- team. 134
holding CPR through the documentation of ‘do not
attempt to resuscitate’ (DNAR) orders, physician orders SUMMARY
for life-sustaining treatment (POLST), advance directives Outcomes for patients after in-hospital sudden cardiac
or living wills 128 (see Chapter 5). For patients or their arrest remain poor. Successful management of a patient
surrogates to meaningfully participate in decision making following SCA depends largely on the timely implemen-
about CPR, they must have some understanding of sur- tation of the chain of survival. Nurses should understand
vival rates and adverse effects associated with CPR. 129 the role of the chain of survival in the resuscitation of the
Consequently, much debate has ensued over the right of person following cardiac arrest. The chain emphasises the
a person to forgo treatment. 125
importance of early recognition and intervention, con-
Research proposes that while patients want to be involved tinuous uninterrupted compressions and the early use of
in CPR decision making and want some form of advance the defibrillator as a BLS skill. Despite the plethora of
directive, their knowledge is limited and often derived research on the topic of resuscitation, there is much we
from television dramas. 128,130 Understanding of morbidity still do not know.

Case study

Thomas was brought into the Emergency Department (ED) at to leave the department. His respiratory rate was 40 with an
1500hrs suffering an acute asthma attack. The paramedics were audible wheeze and a heart rate was 130 beats per minute (sinus
called to his home by Thomas’ mother. Thomas was a 42-year-old tachycardia).
man with an intellectual disability who lived at home with his
elderly mother as his carer. The paramedics stated that they had Thomas was treated for an acute asthma attack in the ED with
inserted intravenous cannula, administered oxygen and salbuta- oxygen, continuous salbutamol nebulisers, ipratropium bromide
mol by nebuliser times three (once on arrival to his home and twice nebuliser and IV hydrocortisone. General screening bloods were
during transport to the ED). On assessment, Thomas was unable to obtained including an arterial blood gas and urea and electrolytes.
speak in sentences and was thrashing around the trolley wanting Non-invasive ventilation with positive end expiratory pressure