Cardiopulmonary resuscitation--time for a change in the paradigm?

Cardiopulmonary resuscitation (CPR) is the default treatment in hospital unless there is a decision to the contrary and this is documented in the patient record. The outcome of CPR in older chronically ill patients is very poor and discharge home is unlikely. Fewer not-for-resuscitation (NFR) orders are written than there are patients who would not benefit from CPR. NFR orders appear to be a marker of death, rather than the result of informed discussion about end-of-life care. There is a legal and ethical framework for the consideration of the suitability of CPR. Discussions about CPR are challenging, and uncertainty is introduced because of the lack of consensus around futility, the emotionally charged nature of the topic, misconceptions about the success of CPR and the failure to recognise that not offering CPR will allow a peaceful and supported death. Discussion around CPR can be misconstrued as a need for consent. A focus on patient and family involvement may result in an expectation that CPR is an entitlement. As part of evidence-based patient-centred care, CPR should only be offered to those for whom it is beneficial. CPR should no longer be the universal default. We propose an opt-in model, which will drive discussion and evaluation of the efficacy and suitability of CPR for the individual. A CPR discussion should occur on admission for all elderly hospital inpatients.