CARDIOPULMONARY RESUSCITATION

Cardiopulmonary resuscitation (CPR) is an emergency procedure which is attempted in an

effort to return life to a person in cardiac arrest. It is indicated in those who are unresponsive
with no breathing or only gasps. It may be attempted both in and outside of a hospital.
CPR involves chest compressions at a rate of at least 100 per minute in an effort to create
artificial circulation by manually pumping blood through the heart. In addition the rescuer may
provide breaths by either exhaling into their mouth or utilizing a device that pushes air into the
lungs. The process of externally providing ventilation is termed artificial respiration. Current
recommendations place emphasis on high quality chest compressions over artificial respirations
and a method involving only chest compressions is recommended for untrained rescuers.
CPR alone is unlikely to restart the heart; its main purpose is to restore partial flow of
oxygenated blood to the brain and heart. It may delay tissue death and extend the brief window
of opportunity for a successful resuscitation without permanent brain damage. An administering
of an electric shock to the heart, termed defibrillation, is usually needed to restore a viable or
"per fusing" heart rhythm. Defibrillation is only effective for certain heart rhythms, namely
ventricular fibrillation or pulse less ventricular tachycardia, rather than asystole or pulse less
electrical activity. CPR may however induce a shock able rhythm. CPR is generally continued
until the person regains return of spontaneous circulation (ROSC) or is declared dead.

History
In the 19th century, Doctor H. R. Silvester described a method (The Silvester Method) of
artificial respiration in which the patient is laid on their back, and their arms are raised above
their head to aid inhalation and then pressed against their chest to aid exhalation. The procedure

is repeated sixteen times per minute. This type of artificial respiration is occasionally seen in
films made in the early part of the 20th century.
A second technique, called the Holger Neilson technique, described in the first edition of the Boy
Scout Handbook in the United States in 1911, described a form of artificial respiration where the
person was laid on their front, with their head to the side, resting on the palms of both hands.
Upward pressure applied at the patients elbows raised the upper body while pressure on their
back forced air into the lungs, essentially the Silvester Method with the patient flipped over. This
form is seen well into the 1950s (it is used in an episode of Lassie during the Jeff Miller era), and
was often used, sometimes for comedic effect, in theatrical cartoons of the time (see Tom and
Jerry's "The Cat and the Mermouse"). This method would continue to be shown, for historical
purposes, side-by-side with modern CPR in the Boy Scout Handbook until its ninth edition in
1979. The technique was later banned from first-aid manuals in the UK.
However, it was not until the middle of the 20th century that the wider medical community
started to recognize and promote artificial respiration combined with chest compressions as a key
part of resuscitation following cardiac arrest. The combination was first seen in a 1962 training
video called "The Pulse of Life" created by James Jude, Guy Knickerbocker and Peter Safar.
Jude and Knickerbocker, along with William Kouwenhoven and Joseph S. Redding had recently
discovered the method of external chest compressions, whereas Safar had worked with Redding
and James Elam to prove the effectiveness of artificial respiration. It was at Johns Hopkins
University where the technique of CPR was originally developed. The first effort at testing the
technique was performed on a dog by Redding, Safar and JW Perason. Soon afterward, the
technique was used to save the life of a child. Their combined findings were presented at annual
Maryland Medical Society meeting on September 16, 1960 in Ocean City, and gained rapid and
widespread acceptance over the following decade, helped by the video and speaking tour they
undertook. Peter Safar wrote the book ABC of resuscitation in 1957. In the U.S., it was first
promoted as a technique for the public to learn in the 1970s.
Artificial respiration was combined with chest compressions based on the assumption that active
ventilation is necessary to keep circulating blood oxygenated, and the combination was accepted
without comparing its effectiveness with chest compressions alone. However, research over the
past decade has shown that assumption to be in error, resulting in the AHA's acknowledgment of
the effectiveness of chest compressions alone (see Cardio cerebral resuscitation in this article).
Indications
CPR is indicated for any person who is unresponsive with no breathing or only gasps as
breathing as it is most likely that they are in cardiac arrest. If a person still has a pulse, but is not
breathing (respiratory arrest), artificial respirations are more appropriate. However, many people
often have difficulty detecting a pulse and CPR may thus be used.

Methods

CPR training: CPR is being administrated while a second rescuer prepares for defibrillation.
In 2010, the American Heart Association and International Liaison Committee on Resuscitation
updated their CPR guidelines. The importance of high quality CPR (sufficient rate and depth
without excessively ventilating) was emphasized. The order of interventions was changed for all
age groups except newborns from airway, breathing, chest compressions (ABC) to chest
compressions, airway, breathing (CAB). An exception to this recommendation is for those who
are believed to be in a respiratory arrest (drowning, etc.).
Standard
A universal compression to ventilation ratio of 30:2 is recommended for adult and in children
and infant if only a single rescuer is present. If at least 2 rescuers are present a ratio of 15:2 is
preferred in children and infants. In newborns a rate of 3:1 is recommended unless a cardiac
cause is known in which case a 15:2 ratio is reasonable. If an advanced airway such as an
endotracheal tube or laryngeal mask airway is in placed delivery of respirations should occur
without pauses in compressions at a rate of 8-10 per minute. The recommended order of
interventions is chest compressions, airway, breathing or CAB in most situations.With a
compression rate of at least 100 per minute in all groups. Recommended compression depth in
adults and children is about 5 cm (2 inches) and in infants it is 4 cm (1.5 inches. As of 2010 the
Resuscitation Council (UK) still recommends ABC for children. As it can be difficult to
determine the presence or absence of a pulse the pulse check has been removed for lay providers
and should not be performed for more than 10 seconds by health care providers. In adults
rescuers should use two hands for the chest compressions, while in children they should use one,
and with infants two fingers (index and middle fingers).
Compression only
Compression only (hands-only) CPR is a technique that involves chest compressions without
artificial respiration. It is recommended as the method of choice for the untrained rescuer or
those who are not proficient as it is easier to perform and instructions are easier to give over the

phone. In adults with out-of-hospital cardiac arrest, compression-only CPR by the lay public has
a higher success rate than standard CPR. The exceptions are cases of drowning, drug overdose,
and arrest in children. Children who receive compression only CPR have the same outcomes as
those who received no CPR. The method of delivering chest compressions remains the same, as
does the rate (at least 100 per minute). It is hoped that the use of compression only delivery will
increase the chances of the lay public delivering CPR.
Interposed abdominal compression
Interposed abdominal compressions may be beneficial in the in hospital environment. There is
however no evidence of benefit pre hospital or in children.
Internal cardiac massage
Internal cardiac massage is the process of cardiac massage carried out through a surgical incision
into the chest cavity. This distinguishes the process from conventional, external cardiac massage,
which is carried out by compression near the sternum during cardiopulmonary resuscitation.
Effectiveness
Type of Arrest

ROSC Survival

Witnessed In-Hospital Cardiac Arrest

48%

22%

Unwitnessed In-Hospital Cardiac Arrest

21%

1%

Bystander Cardio cerebral Resuscitation

40%

6%

Bystander Cardiopulmonary Resuscitation 40%

4%

No Bystander CPR (Ambulance CPR)

15%

2%

Defibrillation within 35 minutes

74%

30%

Used alone, CPR will result in few complete recoveries, and those who do survive often develop
serious complications. Estimates vary, but many organizations stress that CPR does not "bring
anyone back," it simply preserves the body for defibrillation and advanced life support.
However, in the case of "non-shock able" rhythms such as Pulseless Electrical Activity (PEA),
defibrillation is not indicated, and the importance of CPR rises. On average, only 510% of
people who receive CPR survive. The purpose of CPR is not to "start" the heart, but rather to
circulate oxygenated blood, and keep the brain alive until advanced care (especially
defibrillation) can be initiated. As many of these patients may have a pulse that is impalpable by
the layperson rescuer, the current consensus is to perform CPR on a patient who is not breathing.
Studies have shown the importance of immediate CPR followed by defibrillation within 35
minutes of sudden VF cardiac arrest improves survival. In cities such as Seattle where CPR

training is widespread and defibrillation by EMS personnel follows quickly, the survival rate is
about 30 percent. In cities such as New York, without those advantages, the survival rate is only
12 percent.
In most cases, there is a higher proportion of patients who achieve a Return of Spontaneous
Circulation (ROSC), where their heart starts to beat on its own again, than ultimately survive to
be discharged from hospital (see table below). This is due to medical staff either being ultimately
unable to address the cause of the arrhythmia or cardiac arrest, or in some instances due to other
co-morbidities, due to the patient being gravely ill in more than one way.
Compression-only CPR is less effective in children than in adults, as cardiac arrest in children is
more likely to have a non-cardiac cause. In a 2010 prospective study of cardiac arrest in children
(age 117), for arrests with a non-cardiac cause provision by bystanders of conventional CPR
with rescue breathing yielded a favorable neurological outcome at one month more often that did
compression-only CPR (OR 5.54; 95% confidence interval 2.5216.99). For arrests with a
cardiac cause in this cohort, there was no difference between the two techniques (OR 1.20; 95%
confidence interval 0.552.66). This is consistent with American Heart Association guidelines
for parents.
Pathophysiology
CPR is used on people in cardiac arrest in order to oxygenate the blood and maintain a cardiac
output to keep vital organs alive. Blood circulation and oxygenation are required to transport
oxygen to the tissues. The brain may sustain damage after blood flow has been stopped for about
four minutes and irreversible damage after about seven minutes. Typically if blood flow ceases
for one to two hours, the cells of the body die. Because of that CPR is generally only effective if
performed within seven minutes of the stoppage of blood flow. The heart also rapidly loses the
ability to maintain a normal rhythm. Low body temperatures as sometimes seen in neardrowning prolong the time the brain survives. Following cardiac arrest, effective CPR enables
enough oxygen to reach the brain to delay brain death, and allows the heart to remain responsive
to defibrillation attempts.
Adjunct devices
While several adjunctive devices are available none other than defibrillation as of 2010 have
consistently been found to be better than standard CPR for out of hospital cardiac arrest. These
devices can be split in to three broad groups - timing devices, those that assist the rescuer to
achieve the correct technique, especially depth and speed of compressions, and those which take
over the process completely.
Timing devices

They can feature a metronome (an item carried by many ambulance crews) in order to assist the
rescuer in getting the correct rate. Some units can also give timing reminders for performing
compressions, breathing and changing operators.
Manual assist devices
Studies have shown that audible and visual prompting can improve the quality of CPR and
prevent the decrease of compression rate and depth that naturally occurs with fatigue, and to
address this potential improvement, a number of devices have been developed to help improve
CPR technique.
These items can be devices to placed on top of the chest, with the rescuers hands going over the
device, and a display or audio feedback giving information on depth, force or rate, or in a
wearable format such as a glove. Several published evaluations show that these devices can
improve the performance of chest compressions.
As well as use during actual CPR on a cardiac arrest victim, which relies on the rescuer carrying
the device with them, these devices can also be used as part of training programs to improve
basic skills in performing correct chest compressions.
Certain defibrillation pads are capable of performing similar function, in that they may display
rate and depth of compressions. Additionally, a certain algorithm may allow them to monitor
electrical activity even during CPR.
Automatic devices
There are also some automated devices available which take over the chest compressions for the
rescuer. These have several advantages: they allow rescuers to focus on performing other
interventions; they do not fatigue and begin to perform less effective compressions, as humans
do; and they are able to perform effective compressions in limited-space environments such as
air ambulances, where manual compressions are difficult. These devices use either pneumatic
(high-pressure gas) or electrical power sources to drive a compressing pad on to the chest of the
patient. One such device, known as the LUCAS, was developed at the University Hospital of
Lund, is powered by the compressed oxygen supplies already standard in ambulances and
hospitals, and has undergone numerous clinical trials, showing a marked improvement in
coronary perfusion pressure and return of spontaneous circulation.
Another system called the Auto Pulse is electrically powered and uses a large band around the
patients chest which contracts in rhythm in order to deliver chest compressions. This is also
backed by clinical studies showing increased successful return of spontaneous circulation.
Prevalence

Chance of receiving CPR

Various studies suggest that in out-of-home cardiac arrest, bystanders, lay persons or family
members attempt CPR in between 14% and 45% of the time, with a median of 32%. This
indicates that around a third of out-of-home arrests have a CPR attempt made on them. However,
the effectiveness of this CPR is variable, and the studies suggest only around half of bystander
CPR is performed correctly.
There is a clear correlation between age and the chance of CPR being commenced, with younger
people being far more likely to have CPR attempted on them prior to the arrival of emergency
medical services. It was also found that CPR was more commonly given by a bystander in public
than when an arrest occurred in the patient's home, although health care professionals are
responsible for more than half of out-of-hospital resuscitation attempts. This is supported by
further research, which suggests that people with no connection to the victim are more likely to
perform CPR than a member of their family. This is likely because of the shock experienced by
finding a family member in need of CPR; it is easier to remain calm - and think clearly - when
the person in need of CPR is a complete stranger, as in this case one will not be as frightened.
There is also a correlation between the cause of arrest and the likelihood of bystander CPR being
initiated. Lay persons are most likely to give CPR to younger cardiac arrest victims in a public
place when it has a medical cause; victims in arrest from trauma, exsanguinations or intoxication
are less likely to receive CPR.
Finally, it has been claimed that there is a higher chance of CPR being performed if the
bystander is told to only perform the chest compression element of the resuscitation.
Chance of receiving CPR in time
CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops,
because permanent brain cell damage occurs when fresh blood infuses the cells after that time,
since the cells of the brain become dormant in as little as 46 minutes in an oxygen deprived
environment and the cells are unable to survive the reintroduction of oxygen in a traditional
resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate with
cardiac arrest intervals of 7243 minutes; traditional methods achieve a 15% survival rate in this
scenario, by comparison. New research is currently needed to determine what role CPR,
electroshock, and new advanced gradual resuscitation techniques will have with this new
knowledge. A notable exception is cardiac arrest occurring in conjunction with exposure to very
cold temperatures. Hypothermia seems to protect by slowing down metabolic and physiologic
processes, greatly decreasing the tissues' need for oxygen. There are cases where CPR,
defibrillation, and advanced warming techniques have revived victims after substantial periods of
hypothermia.

Society and culture

Portrayed effectiveness
CPR is often severely misrepresented in movies and television as being highly effective in
resuscitating a person who is not breathing and has no circulation. A 1996 study published in the
New England Journal of Medicine showed that CPR success rates in television shows were 75%
for immediate circulation, and 67% survival to discharge. This gives members of the public an
unrealistic expectation of a successful outcome. When educated on the actual survival rates, the
proportion of patients over 60 years of age desiring CPR should they suffer a cardiac arrest drops
from 41% to 22%.
Stage CPR
Chest compressions are capable of causing significant local blunt trauma, including bruising or
fracture of the sternum or ribs. Performing CPR on a healthy person may or may not disrupt
normal heart rhythm, but regardless the technique should not be performed on a healthy person
because of the risk of trauma.
The portrayal of CPR technique on television and film often is purposely incorrect. Actors
simulating the performance of CPR may bend their elbows while appearing to compress, to
prevent force from reaching the chest of the actor portraying the victim. Other techniques, such
as substituting a mannequin torso for the "victim" in some shots, may also be used to avoid
harming actors.
Self-CPR hoax
A form of "self-CPR" termed "Cough CPR" was the subject of a hoax chain e-mail entitled
"How to Survive a Heart Attack When Alone" which wrongly cited "Via Health Rochester
General Hospital" as the source of the technique. Rochester General Hospital has denied any
connection with the technique.
Rapid coughing has been used in hospitals for brief periods of cardiac arrhythmia on monitored
patients. One researcher has recommended that it be taught broadly to the public.
However, cough CPR cannot be used outside the hospital because the first symptom of cardiac
arrest is unconsciousness in which case coughing is impossible, although myocardial infarction
(heart attack) may occur to give rise to the cardiac arrest, so a patient may not be immediately
unconscious. Further, the vast majority of people suffering chest pain from a heart attack will not
be in cardiac arrest and CPR is not needed. In these cases attempting cough CPR will increase
the workload on the heart and may be harmful. When coughing is used on trained and monitored
patients in hospitals, it has only been shown to be effective for 90 seconds.

The American Heart Association (AHA) and other resuscitation bodies do not endorse "Cough
CPR", which it terms a misnomer as it is not a form of resuscitation. The AHA does recognize a
limited legitimate use of the coughing technique: "This coughing technique to maintain blood
flow during brief arrhythmias has been useful in the hospital, particularly during cardiac
catheterization. In such cases the patients, ECG is monitored continuously, and a physician is
present."
In other animals
It is entirely feasible to perform CPR on animals, including cats and dogs. The principles and
practices are virtually identical to CPR for humans. One difference is that resuscitation is usually
done through the animal's nose, not the mouth. One is cautioned to only perform CPR on
unconscious animals to avoid the risk of being bitten and that animals, depending on species,
have a lower bone density than humans, causing bones to become weakened after CPR is
performed.
END OF LIFE CARE
End-of-life care requires a range of decisions, including questions of palliative care, patients'
right to self-determination (of treatment, life), medical experimentation, the ethics and efficacy
of extraordinary or hazardous medical interventions, and the ethics and efficacy even of
continued routine medical interventions. In addition, end-of-life often touches upon rationing and
the allocation of resources in hospitals and national medical systems. Such decisions are
informed both by technical, medical considerations, economic factors as well as bioethics. In
addition, end-of-life treatments are subject to considerations of patient autonomy.
Caring for dying patients is inseparable from our efforts as physicians to improve our patients
lives. The increasingly large number of patients who are part of our aging population along with
technologic advancements make it vitally important to improve and refine our teaching of endof-life care. One of medicines most important missions is to allow terminally ill patients to die
with as much dignity, comfort and control as possible. In patients for whom a cure is not
possible, there is still an enormous amount of care and support that can and should be provided
for patients and their families. Many of the tenets embodied in family medicine are very
important in the care of the dying. A holistic approach to the patients physical and psychosocial
well-being, a focus on the family, continuity of care and an emphasis on quality of life are four
important principles that make the family physician uniquely suited to care for the terminally ill.
The end of life is one of the most critical times in the doctor-patient relationship. A family
physician providing and coordinating hospice or other team care for a dying patient can ease
physical symptoms and provide social, emotional and spiritual support. The care and support
provided can set the stage for some of the most meaningful experiences in which human beings
participate. The time and care surrounding a loved ones death are not just remembered for days

or weeks but often lifetimes. Appropriate teaching and experiences in end-of-life care during
residency training will not only provide necessary information to help ease pain and suffering,
but it will also inspire family physicians to participate in the ultimate continuity of care: that of
the terminally ill.
Competencies
At the completion of residency training, a family medicine resident should:
Be able to identify a plan of care for terminally ill patients, which is based upon a
comprehensive interdisciplinary assessment of the patient and familys expressed values, goals
and needs, and communicate the plan to the patient and family.(Patient Care, Medical
Knowledge, Interpersonal Communications)
Optimize treatment plans for terminally ill patients via integrating knowledge of local palliative
and hospice care resources, as well as state and federal resources.(Practice-based Learning,
Systems-based Practice)
Recognize the signs and symptoms of the imminently dying patient. (Medical Knowledge)
Demonstrate systematic recognition, assessment and management of pain syndromes utilizing
evidence-based medicine. This should include both pharmacologic (opiate and non-opiate) and
nonpharmacologic treatments as well as possible side effects. (Patient Care, Medical Knowledge,
Practice-based Learning)
Be aware of the ethical and legal issues from which the terminally ill patients preferences and
choices may be based upon and/or limited within. Further, skillfully negotiate treatment
decisions with terminally ill patients and his or her family within this context. (Professionalism,
Interpersonal Communications) Attitudes
The resident should demonstrate attitudes that encompass:
The process of breaking bad news, including choice of setting, talking with the patient and
family members, summarizing, using appropriate wording and questioning and the impact of this
process on the patient and family.
An understanding of the psychosocial issues and family dynamics affecting the terminally ill
patient.
An understanding of the spiritual and religious issues affecting the terminally ill patient.
An understanding of the family cultural issues and particular customs in the context of death
and dying.
An understanding of the dying patients need for palliative care, pain relief, control and dignity.

 An understanding of the special issues associated with children, either as terminally ill patients
or as family members of a terminally ill patient.
An understanding of the impact of attitudes and experiences about death and dying in relation
to caring for terminally ill patients.
Knowledge
In the appropriate setting, the resident should demonstrate the ability to apply knowledge of:
1. The philosophy of palliative care
a. Home-based approach
b. Family-as-care unit
c. Pain control
d. Symptom control
2. Hospice team roles
a. Physician
i. Identification of appropriate patients for hospice care
1). Cancer-related
2). Noncancerous-related
a). Pulmonary
b). Cardiovascular
c). Neurologic
d). Infectious
ii. Referral process and criteria
iii. Insurance and medicare coverage
iv. Cost of care for terminally ill in various settings
b. Nurses c. Social worker
d. Pharmacists
e. Home health care aides

f. Volunteers
g. Family
3. Prognosis of terminal illness
a. Accuracy of prognosis
b. Clinical indicators of time until death
c. Value of medical therapies
d. Psychosocial stages of the dying process for patient and family
4. Major pain syndromes
a. Neuropathic
b. Bone pain
c. Visceral pain
d. Nonphysiologic pain
5. Pain control
a. Opiates (long- and short-acting)
b. Nonopiates
c. Addiction, habituation and dependence
d. Baseline dosing and rescue
e. Complementary and alternative medicines
f. Nonpharmacologic pain control measures
g. Side effects of pain control measures
6. Causes and treatment of nonpain symptoms
a. Nausea
b. Shortness of breath
c. Loss of appetite
d. Vomiting

e. Sleeplessness
f. Depression
g. Anxiety
h. Cough
i. Constipation
j. Diarrhea k. Xerostomia
7. Nutrition and hydration in the terminally ill
a. Artificial feeding
b. Intraveneous fluids
c. Withholding feeding and fluids
8. Care locations
a. Emergency department
b. Inpatient
c. Outpatient
d. Extended-care facilities
e. Home
9. Data related to end-of-life care in the United States
a. Aging population
b. Most common chronic illnesses
c. Most common causes of death by age
d. Cost of care for the terminally ill in various settings
e. Where people die (home vs in hospital)
10. The bereavement process
a. Normal grief reaction
b. Differentiate grief reaction from depression

11. Legal issues

a. Patient competency
b. Advance directives
c. Do-not-resuscitate (DNR) orders
d. Power of Attorney for health care
e. Living will
f. Estate planning for patient and family
g. Withholding and withdrawing life support
h. Pronouncement of death
i. Completion of death certificate Skills
In the appropriate setting, the resident should demonstrate the ability to independently perform or
appropriately refer:
1. Physical assessment with attention to common findings of the terminally ill patient
2. Correct compliance with regulations pertaining to use of controlled substances in the
terminally ill patient in and outside hospice care
3. Development of an initial and ongoing analgesic regimen to include the use of morphineequivalent dosages and other narcotic equivalents
4. Effective use of alternative routes of analgesia
a. Rectal
b. Topical (e.g., creams, gels, patches)
c. Nasal
d. Subcutaneous
5. Correct use of pain scales to adjust medication dosage
6. Effective referral of available social services for both patient and family
7. Effective counseling of family and others
a. The process of the death and dying of a loved one via direct communication,

family conferences and creation of a multidisciplinary team for resolution

b. Grief reaction
c. Continuing relationships with family members after a loss
8. Self-care and seeking support when patients die
Implementation
This curricular segment lends itself to a combination of longitudinal and block learning
experiences over the 3 years of residency training. The curricular content should be integrated
into the core conference schedule and should include exposure to hospice care, home visits and
bereavement counseling whenever possible. Relevant literature should be available in the
resident library. An attempt should be made to include patients who have terminal illnesses in all
resident-patient panels. The faculty should function as role models for residents dealing with
dying patients and their families. Active learning techniques such as role playing, simulated
patients, case discussions and topic presentations are useful
The Dying Persons Bill of Rights
1. I have the right to be treated as a living human being until I die.
2. I have a right to maintain a sense of hopefulness, however changing its focus may be.
3. I have the right to be cared for by those who can maintain a sense of hopefulness
however changing it might be.
4. I have the right to express my feelings and emotions about my approaching death in my
own way.
5. I have the right to participate in decision concerning my care.
6. I have the right to expect continuing medical nursing attention even though CURE
goals must have change to COMFORT goals
7. I have the right not to die alone.
8. I have the right to be free from pain.
9. I have the right to have my questions answered honestly.
10. I have the right not to deceive.
11. I have the right to have help from and for my family in accepting my death.
12. I have the right to die in peace and in dignity.
13. I have the right to retain my individuality not to be judged for my decisions which may
contrary to the beliefs of others.
14. I have the right to expect that the sanctity of the human body will be respected after
death.
15. I have the right to be cared for my caring, sensitive, knowledgeable people who will
attempt to understand my needs and will be able to gain some satisfaction in helping me
face my death.

Nursing Care of Dying Patient

Physiological Needs
According to Maslows Hierarchy of needs, physiological needs must be met before
others, because they are essential for existence.
Areas that are often problematic for the terminally ill client are respirations, fluids &
nutrition, mouth, eyes and nose, mobility, skin care and elimination.
Respiration: Oxygen is frequently ordered for the client experiencing laboured breathing.
Suctioning may be needed to remove secretions that the client is unable to swallow.
Fluids & Nutrition:
The refusal of food and fluids is almost universal in dying clients. It is believed
that the client is not feeling thirst and hunger.
Although the issue of permitting dehydration in terminally ill clients is often met
with great resistance.
Artificial nutrition often increases the client agitation leads to increased use of
limb restraints and increases the risk of aspiration pneumonia.
Hospice nurses have indicated that withholding artificial nutrition is not painful.
Regardless, in every situation, the client the clients own wishes must always take
precedence.
If the comatose client has not previously made his wishes known, family members
must be given accurate and truthful information.
For the person in irreversible coma, withholding artificial nutrition does not
causes death rather it allows life to take its natural course and it should be
discontinue to support nutritionally if the client request.
Mouth, Eyes & Nose:
MOUTH
Oral discomfort is the only documented side effect of dehydration in the terminally ill
client.
Both the administration of oxygen and mouth breathing increase the need for meticulous
oral care. Caregiver can use saliva substitutes and moisturizers to alleviate discomfort.
Regular brushing of teeth should be encouraged and the tongue must also be given the
same attention as is the rest of the mouth.
Ice chips and sips of favourable beverages should be offered frequently and petroleum
jelly applied to the lips.
Oral care must be given every 2-3 hrs to maintain the clients comfort.
EYES

Due to the dryness the eyes may become irritated and artificial tears can alleviate this
discomfort
Therefore wiping off the tears from inner to outer cantus to remove the discharges.

NOSE
The nares may become dry and crusted. Oxygen given by the cannula can further irritate
the nares.
So, a thin layer of water soluble jelly applied to the nares will be helpful to alleviate
discomfort.
Mobility:

As the clients condition deteriorates, mobility decreases. Te client become less able to
move about in bed or to get out of the bed and requires more assistance.
Therefore physical dependence increases the risk of complication related to immobility.
E.g Atrophy &pressure ulcer.

Nursing Management:
Frequently re-positioning according to the patient and considering the underlining
condition of the patient such as arthritis & lung disease.
Passive range of motion exercise should be done 2 times (twice) a day to prevent stiffness
and aching of the joints.
Using a wheelchair can also increase the clients environmental space, giving the client
more mobility, control, and independence.
Skin Care
Prevention of pressure ulcer is the priority. These are painful and can cause secondary
complication such as sepsis and are costly to treat.
In addition to the care of the pressure point keeping the skin clean moisturized promotes
healthy tissue.
The skin should be inspected twice daily.
Gentle massages with soothing lotion are comforting.
Bed bath are adequate if the client cannot get into the tub or sit in the shower chair.
Elimination
Constipation may occur due to the side effects of the analgesics and the lack of physical
activities.
Fluids and foods with high fibre contained can be effective preventive measures for the
client with adequate oral intake.

 It can also be alleviated by maintaining a scheduled time for bowel elimination and
administering suppositories if necessary
The client may have incontinence of bladder and bowel, so the nurse need to check the
client frequently, clean the skin the peri-wash, apply a moisture barrier after each
incontinence episode.
Comfort

Pain relief
Keep the patient clean and dry.
Provide a safe and non threatening environment
Provide a respectful, careful attitude to provide psychological comfort by establishing
good rapport.

Physical environment
A soothing physical environment can significantly increase the clients comfort
Adequate lighting enhances vision without causing discomfort associated with harsh,
glaring light.
Provide night light if patient requires
As the client circulation slightly sluggish, the body temperature will fall, so providing a
light weight comforters will be helpful to warmth without adding uncomfortable weight.
Provide quite and calm environment.( even the phone can be removed if patient find it
disturbing.

Psychosocial needs
Death presents a threat to not only ones physical existence but to ones psychological
integrity.
Even though in the presence of the nurse, the family members should be encouraged and
invited to participated in the clients care, if they desire to do so and the client is willing
Maintain a well groomed appearance is important. cutting the nails, shaving the beard
will help to promote patients dignity.
Combing and brushing the hair not only improves appearance but is also a comforting
and relaxing activity for many clients.
Spiritual needs
The nurses play a major role in promoting the dying clients spiritual comfort. Dying persons are
among the most vulnerable members of the human family
Communicate empathy

Play music
Use touch
Pray with the client
Contact clergy if requested by the client
Read religious literature aloud, at the patient request.

Support for the family

The family member needs to be involved in the care of their dying lived one.
Guilt may be increased by the feeling of powerlessness.
Involving the family members in the treatment is a helpful intervention
The families facing the impending death of the loved one require much support from the
nurses and the care givers.
o Being with the family members is extremely important
o Provide assistance and guidance if the family members have limited coping skills
and inadequate supporting system.
o She must be supportive and non judgmental

Legal consideration during death

The Patient Self Determination Act (PSDA) was incorporated into the Omnibus budget
reconciliation Act (OBRA) of 1990
The Act was intended to provide a legal means for individuals to determine the
circumstances under which life sustaining treatment should or should not be provided to
them. The individuals choice are validated by advanced directives
An advanced directive is any written instruction including a living will or durable power
of attorney for health care that is recognised under state law( Taylor 1995)
The act applied to hospitals, long term care facilities , home care agencies, hospice
programs, and certain health maintenance organisations (HMOS)
All the clients entering into the healthcare system through this organisation must be given
information regarding the complete care. It is necessary not only to inform about the care
but also the need to indicate the wishes in regarding to artificial feeding, intubation,
chemotherapy, surgery, blood transfusion etc.
Although the living will and durable power of attorney for health care are legal
documents, they do not preclude the need for resuscitation
The medical record must have a written DNR (Do-Not-Resuscitate) order from a
physician if this is in agreement with the client wishes and with the advanced directives.
In the absence of this order resuscitation is not initiated.

Ethical consideration during dying

 Death is often fraught with ethical dilemmas that occur almost daily in health care
settings.
Many health care agencies have ethics committees to develop and implement policies to
deal with and to end-to-life issues
Ethical decision making is a complex issue. One of the most ethical dilemmas is
determining the difference between killing and allowing someone to die with holding
life-sustaining treatment methods.
The ANA distinguish reliving pain and mercy killing( euthanasia or assisted suicide)
Pain relief is a central value in nursing, where as euthanasia is viewed as unethical.
The ANAs position is that increasing dose of medication to control pain in terminally ill
client is ethically justified even at the expenses of maintaining life.

CONCLUSION
CPR is an emergency procedure which is attempted in an effort to return life to a person in
cardiac arrest. It is indicated in those who are unresponsive with no breathing or only gasps. It
may be attempted both in and outside of a hospital. CPR alone is unlikely to restart the heart; its
main purpose is to restore partial flow of oxygenated blood to the brain and heart. It may delay
tissue death and extend the brief window of opportunity for a successful resuscitation without
permanent brain damage

BIBLIOGRAPHY
Lewis Heitkember, Dirksen, O`Brien, Bucher , Medical surgical nursing , Assessment
and management of clinical problems, Mosby publication , volume 1st, Pp no :
Joyce .M.Black, Jane Hokanson Hawks, Medical Surgical Nursing, Clinical
management for positive outcome, Elsevier publication, seventh edition, volume 1st, Pp
no:.
ARLENE.POLASKI,SUZANNE E.TATRO Luck mans Core Principles and Practice of
Medical Surgical Nursing, Saunders publication, Pp no;
Suzanne.C.Smeltzer,Brinda.G.Bare, Brunner and Siddharthas Text Book of Medical
Surgical Nursing, Lippincott publication, ninth edition, volume 1st, Pp no;
Potter. Perry, Basic Nursing Essentials for Practice, Mosby Elsevier publication, fifth
edition, volume 1st,Pp no:
S.N Nanjunda Gowda, Basic principles and Practice of Nursing J.N publication,1st
edition, Pp no :

AECS MAARUTI COLLEGE OF

NURSING
SUBJECT: ADVANCED NURSING
PRACTICE.
TOPIC: cardio pulmonary
resuscitation and end of life
care

SUBMITTED TO

SUBMITTED BY

Mrs. Shoba Naik

Anitha.B

Professor

1ST YR M.Sc Nursing