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National Patient Safety Agency

Clinical Articles, News & Views

Premature diagnosis of death after CPR

Death is being prematurely diagnosed after failure to respond to cardiopulmonary resuscitation (CPR), causing unnecessary distress to families, according to a signal statement released recently by the UK’s National Patient Safety Agency (NPSA).

The statement also reports five incidents where the family was prematurely informed that the patient had died at the point the resuscitation attempt was stopped, but where the patient actually survived a few more hours, reported to the National Reporting and Learning Service (NRLS) between 1 January 2009 and 31 December 2011.

These incident reports do not suggest the decision to stop the resuscitation attempt was incorrect, the statement says, or that the outcome for the patient would have been any different had the resuscitation continued – the harm was in the distress caused to the patients’ families, it states.

In the incidents reported to the NRLS, the problems appear to have arisen because staff wanted to break the news of the patient’s death to the patient’s family as soon as possible, and therefore spoke to the family in advance of carrying out formal procedures for confirming death, it concludes.

The statement cites a case in which a patient with multiple serious medical conditions developed chest pain and collapsed, after which resuscitation was attempted.  ”After approximately 25 minutes the resuscitation team called off the resuscitation and declared to the family that the patient had died. When the patient’s family walked in to see the patient they realised she was still showing respiratory movement …… the patient regained spontaneous respiratory activity and an output”.

“She did not regain consciousness and it was felt that she should not be for any intensive management and should be kept comfortable and she finally died [eight hours later] ……Understandably, the family were extremely distressed about the whole situation.”

Signal statement available in full from: http://www.nrls.npsa.nhs.uk/signals/?entryid45=132973

The Code of practice for the diagnosis and confirmation of death from the Academy of Medical Royal Colleges provides guidance on how to diagnose and confirm death. The actions required to confirm death after stopping cardiopulmonary resuscitation attempts are described on page 12 of this guidance. This includes observing cardiorespiratory arrest for a minimum of five minutes.

Published on: April 18, 2012

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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