This Signal aims to avoid unnecessary distress to families caused by the incorrect diagnosis of death after a patient fails to respond to cardiopulmonary resuscitation.
A report received by the NPSA reads:
“Patient with [multiple serious medical conditions] developed chest pain, collapsed.....[cardiac arrest call and resuscitation attempts detailed]. 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.”
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, have been reported to the NRLS between 1 January 2009 and 31 December 2011. Through clinical contacts, and a review of NHSLA data, we are aware of five additional cases of this nature. These numbers are likely to be an underestimate as it is difficult to indentify such reports within the NRLS. These incident reports do not suggest the decision to stop the resuscitation attempt was incorrect, 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.
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.
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.
Local organisations may wish to use this Signal to prompt their resuscitation teams to discuss and plan how to handle communication with relatives at the point where resuscitation attempts are stopped.
We would like to hear from you - please contact us with your initiatives to reduce risks in these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.