Reflective account of a case seen in practice in a pre-hospital setting
I am a Paramedic registered with the health & care professions council (HCPC) and this essay will look reflectively at an incident I attended during the course of my duties. This case reflection aims to reflect on an encounter with a patient in pre-hospital care with which I was challenged during this particular emergency and were at that time available pathways to guide patient management have been questioned. Confidentiality has been maintained at all times and names of individuals will not be disclosed (HCPC 2014)
To analyse this critical incident, Gibbs Reflective Cycle will be used (Gibbs, 1998).
As a front line Paramedic working for the Ambulance service I attend multiple categories of emergencies during my tours of duty. I work in a team with my colleague, trained as a Trainee Emergency Ambulance Crew (TEAC), on a Double Crewed Ambulance (DCA). The incident I will be reflecting on occurred whilst working a regular shift during my first year with the current Ambulance service.
On this day we were dispatched to a residential address where a 70-year-old male was not responding and had been reported with noisy breathing by his carer. We arrived on scene and upon entering the premises we found the patient to be in cardiac arrest with active cardio-pulmonary resuscitation (CPR) being conducted by the already on scene Fast Response Unit (FRU) Ambulance Technician who also had been dispatched to the incident. After introducing ourselves to our colleague we received the handover, stating the patient had been found by his carer not responding and with irregular breathing pattern in his hospital bed. Basic Life Support (BLS) was continued, followed by initiating Advanced Life Support (ALS). Assessing the scene and social circumstances, an advanced illness came soon apparent with this patient, as there was a hospital bed, home oxygen, and a wide variety of care supplies identified. Unfortunately communication with the present carer was not effective and statements about the history of the incident were inconclusive. Soon a district nurse team arrived and stated they would provide the patient with End of life care (EoL) and a Do not attempt cardio-pulmonary resuscitation (DNACPR) decision would be in place. The patient was reported to be suffering from end stage chronic obstructive pulmonary disease (COPD) and cancer. However a DNACPR form could not be found and neither the district nurse nor the carer was able to produce questioned document. Since no evidence of a DNACPR was found cardiopulmonary resuscitation was continued by the Ambulance crew and additional back up was requested. During on-going ALS the district nurse contacted her office and stated a DNACPR document has been initiated but does not physically exist at this time. After the patient kept partially responding to our treatment but did not sustain a stable Return of spontaneous circulation (ROSC) the Clinical support desk (CSD) was consulted via telephone and resuscitation effort were discontinued as social and illness related circumstances suggested CPR to be futile.
At the beginning of the incident I was quite frustrated as it was very difficult to gather any information about the patient and his medical condition or what happened to the patient and when. Especially after the arrival of the district nursing team on scene who stated the patient would receive EoL care and given his advanced medical condition, I thought this patient would not benefit from CPR attempts and I did not think it would be ethical to continue. However, it is fairly common practice and part of professional guidelines (JRCALC 2016) in Ambulance services to initiate and continue CPR unless a valid DNACPR is physically produced. The British Medical Association (BMA), the Resuscitation Council (UK), and the Royal College of Nursing (RCN) stated in a guidance publication from 2016: Most healthcare organizations have a policy that requires an initial presumption to attempt CPR in a person who dies or suffers sudden cardiac arrest in the absence of a valid, recorded anticipatory decision that CPR will not be attempted. Given my time with this Ambulance service of less than 1 year at the time, I was still slightly insecure about decisions in this case as I was not entirely familiar with the Trusts detailed guidelines regarding discontinuing CPR. The HCPC list one of my duties as a registrant as: You must keep within your scope of practice by only practising in the areas you have appropriate knowledge, skills and experience for. and You must refer a service user to another practitioner if the care, treatment or other services they need are beyond your scope of practice. (HCPC Standards of conduct performance and ethics, 3.1, 3.2 2016). After consulting with CSD and discontinuing CPR I felt as this was a good decision and we acted in the patients best interest. The most frustrating part for me at the time was that I was not able to base my clinical impression and ethical concerns on existing protocols and guidelines and a decision against continued CPR could have been made at an earlier stage.
Looking at the incident I feel there were lots of positives, these include fast and effective communication with the first responder, continuing effective CPR and initiating ALS in a very effective way, following all pathways and protocols. Conversations with our own CSD were also very effective and a good final team decision had been made with everyone involved being happy about the outcome and acting in the best interest of the patient. However, it was rather frustrating that at the time not enough information could be gathered from the carer about the patients conditions due to a possible language barrier and the lack of available care records and documentations.
According to Feder G., (1994), conflicting guidelines from different professional bodies and sources can also confuse and frustrate the healthcare professional. Just looking at this case there are amongst many others following guidelines regarding decisions when to not initiate or discontinue CPR on patients without a DNACPR in place:
A patient in the final stages of a terminal illness where death is imminent and unavoidable and CPR would not be successful, (JRCALC, 2016);
Evidence of Terminal/advanced illness documented in the patients DN/community notes. (LAS Advanced care planning guidance, undated);
, patient in the dying phase of their illness?, evidence of their EoLC status (LAS Cardiac care guidance, 2018)
final stages of an advanced and irreversible condition, in which attempted CPR would be both inappropriate and unsuccessful, (Resuscitation Council (UK), 2015)
One can easily see how definitions vary and how this can clearly confuse the healthcare professional on scene. Looking at some of the definitions, the Marie Curie Charity (2018) defines terminal phase or dying phase as The last days or hours of a persons life that can present with 17 individual symptoms. The National health service (NHS) states following regarding EoL: People are considered to be approaching the end of life when they are likely to die within the next 12 months, (NHS, 2018) A clear definition for a advanced and irreversible condition could not be found at the time of this essay.
Since decisions to not initiate or discontinue CPR attempts will always be challenging and most likely be based on a individual patients condition and circumstances, the clinician must make an appropriate decision and always act in the patients best interest guided by what they would have chosen for themselves (Resuscitation Council (UK), 2015). From this experience, I am now more confident and assured in my practice as I found my experience as a Health care professional (HCP) and my professional beliefs being in conjunction with the result of my research. Given the current state of knowledge and information I would have felt more confident and a decision to cease CPR could have been made sooner to follow the patients best interest in given circumstances. I have also learned that DNACPRs do not have to be physically present on scene and when notified by a registered HCP of an existing DNACPR, CPR can be stopped with their name and registration number recorded (LAS ACP guidance, undated).
In the future, I aim to be more confident in dealing with a situation where no DNACPR is in place and it does not feel right to initiate or continue CPR based on the patients circumstances, medical conditions and information available. Moreover, I will address the best interest of the patient or assumed best interest if no information suggesting their wishes can be found (Resuscitation Council (UK), 2015). I will continue to undertake regular professional reflective practice, using the on-going model proposed by Gibbs (1988). I also plan to present this essay to the Clinical Advisor to the Medical Director of the London Ambulance Service (LAS), to question the efficacy of current guidelines and possibly reducing the confusion in definitions regarding final stages of a patients life and to further improve care and management in decision making in cardiac arrest patients and to advocate and support clinicians professional impressions of a individual case.
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