DNACPR and ReSPECT — the honest conversation

PLAB 2 & PRES 3 · ethics / respiratory medicine · hard · 10 minutes

Candidate brief

You are an FY2 doctor on a respiratory ward. Mr Alan Shepherd, 74, has advanced COPD: FEV1 28% predicted, long-term oxygen at home, two admissions with non-invasive ventilation (NIV) in the past year, the most recent six weeks ago. He is now recovered from this admission's exacerbation and is due for discharge tomorrow. The consultant has asked you to discuss emergency care planning with him, including the team's recommendation — which you are to convey and explore with him — that cardiopulmonary resuscitation (CPR) would not be attempted if his heart stops, and to complete a ReSPECT form with him. Please conduct this discussion.

What examiners look for

CPR in advanced COPD is not a coin the patient flips; it is a treatment with a physiology. An arrest caused by hypoxia in end-stage lungs, treated with compressions on osteoporotic ribs, rarely produces a survivor — and when it does, it produces the ventilated ICU dying his family dreams about. Saying so, kindly and in his numbers rather than television's, is the clinical content of this conversation. Never ask "do you want CPR?" of a patient for whom the team believes it would fail. That question converts a clinical recommendation into the patient's personal death decision, and he will carry "I chose to die" to his grave's doorstep — as will his widow. Instead: recommend, explain, invite his view, record it, honour dissent with review and second opinion. The duty after Tracey is to consult — a real duty — but consultation is not abdication. The ReSPECT frame is the clinician's friend: begin with his life (home, Beryl, the garden), derive what emergency care should protect, and let the CPR recommendation sit inside a plan that is mostly about what WILL be done — NIV, antibiotics, place of care, who to call. A conversation that is 80% about continuing treatment earns the right to its 20% about CPR. The sentence that does the heaviest lifting is the firewall: "This changes one thing only — the chest compressions. Everything else we do for you stays exactly as it is, including the mask that has worked twice." Repeat it at every tremor of "giving up on me", because that fear, unaddressed, outlives the consultation and poisons every future admission. And let him own the telling. The man who says "I'll tell Beryl myself tonight" has transformed from recipient of a decision into author of his own plan — which is what advance care planning is for. Your job is to make sure that when he explains it at the kitchen table, he explains it RIGHT: no thumping, everything else, his words on the form.

Guideline references

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