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.