Thursday, 1 June 2017

The Latest CPR Update

As a nurse I have performed CPR a lot of times in my career and the worst times have been when it was obvious that we had no chance of getting the person back. The futility of performing CPR when it is plain that the person had died and what we are doing was having no positive effect can be so depressing and can sap your strength. When the person in charge of such a resuscitation calls an end to it all it can come as a physical relief.

I was horrified to read the case of Jane Kendall (1). She was found guilty of misconduct and had imposed a Caution order on her for 2 years (2) because she didn’t perform CPR on a patient who had died; but the facts turn a different light onto it all.

Miss Kendall works in a nursing home, she was the nurse on duty, on a night shift in November 2014. During the night a Healthcare Assistant came to her and told her a resident was “unresponsive”. Miss Kendall found the resident had died. The resident had no pulse, wasn’t breathing and had no vital signs of life. The resident was “waxy, yellow and almost cold”, Miss Kendall said. She saw that the resident was dead and she didn’t start CPR. Death was confirmed by paramedics, later that day. The problem was that the resident didn’t have a DNAR in place (a Do Not Attempt Resuscitation notice) (2).

The police investigation found that there was nothing suspicious about the resident’s death. The police investigate all unexpected deaths. The Coroner found that the resident died from natural causes. There was nothing suspicious about the resident’s death (2).

The Nursing and Midwifery Council (NMC) found Miss Kendall guilty of misconduct. Their ruling talked about Miss Kendall “in the past put patients at unwarranted risk of harm(2). This is an unbelievable claim to make. Miss Kendall didn’t harm a patient, she didn’t put any patient’s health or well-being at risk. What she didn’t do was perform CPR on a patient who had been death for a long period of time.

The NMC ruling (2) talked a lot about Miss Kendall’s actions and the “risk” she did and did not prose, but there was no discussion of the fact that the patient was already dead and neither was there any discussion of current policy and guidelines about CPR.

Firstly, in Miss Kendall’s evidence she said the resident was “waxy, yellow and almost cold” (2), with no pulse, not breathing or any vital signs of life. She was not describing someone who had just died but someone who died some time ago. Rigor Mortis starts within 2 hours after death (3), the signs of it are that muscles become firm and then rigid, starting with the small muscles in the face and hands, and a rapid cooling of the body (3). Her description of the resident as “waxy, yellow and almost cold” (2) implies that Rigor Mortis had begun. How successful would CPR be with someone who has been dead for so long?

Defibrillation needs to delivered with 3 to 5 minutes of someone’s collapse to give survival rates of between 50–70% (4). That is not death but when a person collapses with a cardiac arrest, the longer they have to wait for defibrillation the lower the chance of survival, but this time is measured in minutes and not hours. A person needs to be in a “shockable rhythm”, a condition that responds to defibrillation, and only 20% of people who have cardiac arrests outside of a hospital have a “shockable rhythm” when the paramedics arrive (4). Someone who does not a pulse and is “almost cold” will certainly not have a “shockable rhythm”.

The decision not to attempt CPR is a clinical decision, if the clinical team has good reason to believe that a person is dying as an inevitable result of advanced, irreversible disease or a catastrophic event and that CPR will not re-start the heart and breathing for a sustained period.” Decisions Relating to Cardiopulmonary Resuscitation, a joint statement by the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing (5).

It was not Miss Kendall’s fault that the resident did not have a DNAR in place, the management of the home needs to take responsibility for that, but Miss Kendall was the only nurse on duty when that resident died, she was the only clinical person there to make this decision.

The NMC’s ruling (2) makes no reference to any of this, it does not mention the Resuscitation Council (UK). They are the professional body that provides the most up to date and comprehensive guidelines on CPR, both in hospital and outside of it. They produce the Gold Standard for CPR guidelines, yet the NMC ruling does not mention them once. The ruling talks a lot about the “harm” Miss Kendall caused that resident and yet it does not discuss the fact that the resident had already died and that any attempt at CPR would have been unsuccessful. There is no discussion of the clinical situation here.

Miss Kendall did act outside her scope of professional practice (2), she verified that death had occurred when she had not been formally trained in certifying death. But she is a nurse of many years (She qualified in 1973 (2)), and being able to identify that all vital signs of life have stopped is something many nurses acquire during the cause of their career. If the NMC was so concerned about her doing this why didn’t they make recommendations about all nursing working outside of a hospital being trained to certify death? They didn’t (2).

There has already been concerns raised that nurses will now be pressured into performing CPR when it is obviously pointless following this ruling (1). To me, performing CPR on someone who is dead and with no chance of them responding is not respecting that person’s dignity in death, how can it be with all the physical force involved with CPR?

What worries me most, about this case, is the behaviour of the NMC. Their ruling shows should little understanding and discussion of the clinical situation Miss Kendall faced. There is no discussion of the fact that the resident had obviously died. They make no reference to any guidelines or evidence about CPR performed outside of hospital, and they do not mention once the Resuscitation Council (UK). The only guidelines mentioned in this ruling are the NMC’s own Code of Conduct for Nurses (6).

How can the NMC reach such a potentially far reaching judgement without any reference or discussion of national policy and guidelines, and no discussion of the evidence? This is such a narrow ruling, with no evidence backing it up. If my employer said I had to follow their new CPR policy, and the only reference in it was to another of the Trust’s policies, I would make such a stink about it.

This whole case highlights a problem I feel is at the heart of the NMC, the organisation is run by people who have no nursing or healthcare backgrounds. Jackie Smith, the NMC’s Chief Executive and Registrar, has a background in law, not healthcare (7). How can you regulate nursing when you have little or no experience of healthcare? This ruling shows how little the NMC understands about the realities of day to day nursing.

I work in the community. If I visit a patient at 10 o'clock in the morning and find they have died in the small hours of that day will have I have to perform CPR on them? The NMC says yes, yet they seem to know so little about the realities of my working life.

Drew Payne


Neat Mayhem said...

I feel so sorry for Nurse Kendall, she has been put through the wringer in more ways than one. I qualified in 1983 and many of my skills gained I've had to back up with a paper ticket. But really.....seriously she went beyond her remit of verifying life extinct, and some hours ago to boot, Haven't we all found someone apparently sat watching tv in their chair, curled up under the duvet but having happens, sadly, but that is life's tapestry. I sincerely hope she told the NMC to shove their bills and revalidation bulwarks straight up the suppository route then sit down hard. She has been treated truly appallingly. And I am in disgust!

Unknown said...

The ruling is absolutely disgusting, if she had walked in and the patient was warm then I could see their point ( in a way) but this patient had obviously passed a good while before they were found ... it seems there is always a loop hole that gets people into trouble .
It is seems the only thing she has caught on is that she had not done the verification class .. but really after being trained since 1973 do they really think that she could recognize if the patient would benefit from cpr , or let the patient die with a bit of dignity ..
very sad ... and I hope miss Kendall is dealing ok with this ruling .. not sure I would be staying in the profession .

Scorpion said...

It is of great concern that the NMC found this nurse guilty of misconduct, given the coroner has ruled she died of natural causes. If an experienced nurse is not considered competent enough to make a decision as to whether a patient is dead or not, what the hell is she good for?

Steve said...

My Mother passed away in a nursing home having been ill and bedridden for a year with almost no movement and very little awareness of her surroundings. I had made it very clear that when her life expired there should no attempt to resuscitate.
Then I got the phone call "Sorry your Mother has passed away, we tried our best to resuscitate". Why? Madness, I suspect she didn't suffer from their attempts though I don't know, but why even attempt it?

Bernie said...

Disgraceful that the NMC is more concerned with the law than the physical wellfare and dignity of patients. They sound wholly incompetent as a regulatory body

Unknown said...

In the hospital i work, there was a similar case. I had to witness how the doctors and, before them, the nurse were resuscitating someone which has been dead for at least one hour. The view was horrible. As i stood there and trying to make myself usefull, i was wondering how in these moments they preserve dignity? They were performing this CPR just because they needed to cover their backs, but all the time having in their minds that it was pointless. They stopped when the blood bursted out of that patient's mouth. I felt like that patient was on some butcher's hands. It is incredible to me as an oversea nurse and hard to accept that behind all these there is nothing else but words and a law which missed the whole picture. In my country we are trained to asses death and people have a dignified death. It is sad :(

Comother said...

Shocking to say the least , as a community carer am I supposed to try CPR on someone that has passed away over 10 hours ago ?? It is indescribable the horror of actually trying to resuscitate someone in the first place and the feeling of desolation when it is not successful , I cannot imagine the feelings of someone "forced" to try to resuscitate someone knowing there is not hope of an outcome ....... A lot of people would not want their loved ones to suffer the indignity of an attempted resus which is never pleasant even when there is a chance of survival ........The last time I managed to "get someone back" I broke 4 ribs and then they took 12 hours to die .... for what ???..... If someone has been dead a good few hours WHY ?????????? A pathetic attempt to cover backs and the rule of law needs changing to reflect the situation ...........

Unknown said...

so as a nurse, if i found a loved one dead would i have to resus them when i could clearly see that it was not appropriate. would i be sent to NMC because i am a nurse. what would happen to us nurses if the family of a person who had died and we broke their ribs etc by doing CPR, decided to take us to court for abuse. how would we stand then. why did the representative for the nurse not identify the resus council statements etc. or is NMC a closed shop with no ability to defend ourselves.

Ibizababe said...

I have worked as a qualified nurse in the same Trust for over twenty-five years and it has always been policy that any patient without a DNAR order in place must be resuscitated. I am a senior nurse now, but obviously have worked through the ranks on day and night duty and have been in the situation where I was the only qualified member of staff present on the ward and have found unresponsive patients. However, since as a nurse it is my role to recognise and report abnormal observations to the medical team for action, ie absence of breath sounds, respiration and pulse ('death'), but only doctors or in the case of an 'expected death' with a DNAR in place: senior nurses with the 'certification of expected death' qualification can declare a person 'dead'. Therefore, in this case it would be expected that resuscitation would be commenced and the medical team whom knows the patient to attend the resus as soon as possible and make it clear whether they want the resus to continue or cease as futile. Is this not the same throughout the NHS?

Unknown said...

This is so typical of the NMC is it any wonder that nurses resent paying fees to this so called regulatory body?
There wasn't any harm done as the patient was already dead.
I suggest that all involved in this decision be made to work on a ward for 6 months so they get some bloody understanding of what nursing actually involves, instead of just pushing more rules & regs at us!

PeeJay said...
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PeeJay said...
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PeeJay said...

Steve - My hubby has not long had a DNAR put in place. We were advised that it had to come from him, unless there was a power of attorney held relating to health. Relatives are unable to make that choice for them and, it seems, legally, without that DNAR resuscitation has to be attempted (but surely, not if somebody is so obviously dead) however, in reality I know from experience that relatives are consulted if it becomes clear that somebody is dying and that there is no possibility of their survival even if CPR is attempted. My Mum died from an aortic aneurysm and my mother-in-law from heart failure. In both cases we were asked if CPR should be attempted as part of their treatment. There was no DNAR in place for either but it was obvious neither was going to survive, no matter what treatment was given other than end of life care.
The fact your Mum had no DNAR in place is why they attempted it. They had to but, if they'd asked the question at the relevant time, they may not have done.