Development and implementation of resuscitation guidelines: a personal experience

Objectives: to develop and implement guidelines on the appropriate use of cardiopulmonary resuscitation, which would ensure patient involvement in decision-making about cardiopulmonary resuscitation whenever possible but without offering illusory choices where resuscitation was unlikely to succeed. Design: quantitative guidelines were developed after a review of the Literature on survival after cardiopulmonary resuscitation. Patients were classified according to their estimated likelihood of survival to discharge after resuscitation: <1%, group A; 1-10%, group B; and >10%, group C. Qualitative guidelines were developed after consideration of the legal and ethical principles of cardiopulmonary resuscitation. It was decided to inform competent patients in group A that cardiopulmonary resuscitation would be inappropriate, and to seek the preferences of competent patients in group B. The operation of the guidelines was examined in patients aged 65 years or more admitted under a single consultant in an acute community hospital. Results: 147 patients were studied: 39 in group A, 26 in group B and 82 in group C. Of 36 patients in groups A and B judged competent, cardiopulmonary resuscitation discussions were only undertaken in 17, usually because acute distress or anxiety precluded effective communication. Of the 23 patients or family members from whom cardiopulmonary resuscitation preferences were sought, four opted for full cardiopulmonary resuscitation and six for limited cardiopulmonary resuscitation (usually witnessed-arrest only and no ventilation). Conclusion: it is difficult to involve acutely ill elderly patients in cardiopulmonary resuscitation decision-making. Limited cardiopulmonary resuscitation is a useful option for patients, relatives and doctors.