Treatment escalation and CPR discussion — advanced cancer

PLAB 2 & PRES 3 · communication · medium · 8 minutes

Candidate brief

You are an FY2 doctor/SHO on an acute medical ward. Mr Michael O’Brien, 72, has advanced metastatic pancreatic cancer and is being treated for pneumonia. The medical consultant has reviewed him and believes that cardiopulmonary resuscitation would not provide a sustained clinical benefit if his heart or breathing stopped. The consultant also recommends ward-based treatment rather than invasive ventilation or intensive care. Explore Mr O’Brien’s understanding and priorities, explain the senior team’s recommendations and agree an appropriate treatment-escalation plan. The consultant and palliative-care team are available for further review.

What examiners look for

Treatment-escalation planning is broader than a CPR decision. Discuss each potentially appropriate treatment separately. Begin by exploring what the patient understands, what matters to them and which outcomes they would consider acceptable. Do not begin with an unsupported question such as, “Do you want to be resuscitated?” Explain the clinical situation, describe CPR and provide an individual professional recommendation. CPR is attempted only after the heart or breathing has stopped. It may involve chest compressions, electric shocks, medication, airway procedures and ventilation. A DNACPR or DNAR decision applies only to CPR. It does not automatically mean: No antibiotics. No oxygen or fluids. No hospital admission. No symptom treatment. No palliative care. No other clinically appropriate treatment. Explain the positive care plan as clearly as the treatments that are not recommended. Decisions about intensive care, ventilation, non-invasive support, hospital transfer and treatment of reversible illness must be considered separately. A patient cannot require clinicians to provide treatment that is not clinically indicated. Their concerns, values and preferences must still be heard and considered. When disagreement persists, provide further senior discussion and an independent second opinion. Relatives can support a patient but cannot override a capacitous adult’s decision. Document the discussion, clinical recommendation, patient’s views, agreed treatments, review arrangements and communication across care settings.

Guideline references

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