Rethinking resuscitation: moving the goals

Cardiopulmonary resuscitation (CPR) techniques have developed remarkably since first described. CPR is now both a default treatment and a public expectation. However, anticipated outcomes are not matched by reality. The differences between in- and out-of-hospital cardiac arrests are often not recognised and almost never taught. 'Do Not Resuscitate' orders developed to provide the ability to opt-out of this treatment. Nevertheless, CPR is still inappropriately used in settings where reversibility and likelihood of benefit are not meaningfully considered or discussed with the patient. Further, treatment escalation is a continuum, so resuscitation orders present a false dichotomy of 'do' or 'do not' resuscitate. Asking patients about their goals, and only offering treatments aligned with those goals, allows consideration of the burden of treatment and the likelihood of success. Shared decision models improve communication and patient autonomy. Tools are available to help clinicians with the difficult conversation and document the outcomes. Now, in both our training and practice, it is time to move beyond the stark and often irrelevant choice between CPR and 'Not for Resuscitation'.