This information is for people with cancer who may be asked to discuss the sensitive issue of cardiopulmonary resuscitation (CPR) with their healthcare team. It is a guide to help individuals, their family, friends and carers to understand more about CPR, to enable them to make informed decisions about the care and treatment they want to receive.

Cardiopulmonary resuscitation (CPR) is a way of trying to restart the heart and breathing once they have stopped. When the heart stops beating this is known as a cardiac arrest. If the breathing stops this is called a respiratory arrest. They commonly occur together and this is known as a cardiopulmonary arrest. Death will result if a cardiopulmonary arrest is not corrected urgently.

A cardiac or respiratory arrest may occur for a number of different reasons and is different from a person having a heart attack, which is a particular medical condition.

CPR usually involves pushing down on the chest (chest compressions), and/or giving breaths into the mouth (mouth-to-mouth). Medication is also often given, along with intensive support and monitoring.

CPR is different to other forms of resuscitation to which doctors may refer (for example, using intravenous fluids to 'resuscitate' a person who is severely dehydrated).

If a person experiences a cardiopulmonary arrest in hospital, staff will sound an emergency alarm to alert the healthcare team that there is an emergency situation. An arrest or resuscitation trolley will be taken to the patient. The trolleys contain essential equipment and are available in the main areas of a hospital, as well as on every ward and clinic.

A resuscitation team will also be alerted to come to the patient. This includes a team of healthcare professionals, such as doctors and nurses, who are experienced in dealing with emergency situations.

It can be extremely distressing to see CPR being attempted, especially if it is a loved one who is unwell. Sometimes families will be asked to leave the area and they will be kept informed of what is happening.

Most people will not experience a cardiopulmonary arrest during a hospital admission. However, hospitals are now required to have a policy that states that CPR is discussed with each patient soon after their admission to hospital. This is to ensure that you are included in making the decision about whether or not CPR should be attempted if your heart or breathing stops.

As each situation is unique, the topic of CPR needs to be dealt with sensitively. Often doctors will explain if they feel that CPR is unlikely to be successful, especially when someone may be terminally ill. In these situations attempting CPR will almost certainly be unsuccessful and will only cause unnecessary distress to both the patient and their loved ones.

CPR is not always beneficial. Its success depends on many factors, including: the age and general health of the individual; any underlying health problems; the type and extent of the cancer; the main cause of the heart or breathing stopping; and how quickly the heart and breathing can be restarted.

There are over 200 different types of cancer, and many types of cancer treatment, which can affect people in very different ways. Some people may have potentially curable cancers, while others may have cancer that cannot be cured. Each individual situation is different.

If a cancer is very advanced, the heart and breathing may gradually slow down and stop as part of the natural process of dying. In this situation CPR would not be helpful or appropriate, as it is probable that the cancer itself will have affected some vital organs of the body, causing them to gradually stop working.

Sometimes a cancer may be incurable, but the person may be expected to live with the condition for a long while, sometimes years. There may be many reasons why the heart or breathing stop suddenly (such as a serious infection caused by the treatment). In this situation, attempting CPR may be appropriate, but still may not be successful.

There are four possible outcomes following cardiopulmonary resuscitation:

• complete recovery
• partial recovery
• prolonged survival
• death.

Unfortunately, only a small number of people will make a complete recovery and be discharged from hospital. Some may show a partial recovery, but will be left with serious health problems, despite every effort being made to try to help.

For some people survival may be prolonged, often by using an artificial ventilator (breathing machine) in an intensive care unit. While this may extend their life by a matter of hours, days or sometimes weeks, the person's quality of life is usually very poor. For many, CPR will not be successful and, sadly, they will still die.

Ideally, you will be able to discuss your views about CPR with your medical team and say whether you would, or would not, prefer to have CPR if a cardiac or respiratory arrest occurs. However, it is important to remember that in most situations (and particularly when a cancer is very advanced) CPR is not often successful. Doctors will tell you if they feel that there is little chance of CPR working in your situation.

If there has not been any discussion about CPR between a person and their medical team, and their heart or breathing suddenly stops, the decision about whether or not to attempt CPR is made on medical grounds.

If a person states that they do not want CPR to be attempted, their decision is final. The medical team can only override the decision of the person in very rare circumstances where the individual is considered not to be of 'sound mind' (for example, if they have a serious mental illness or are confused or disorientated).

Thinking about and discussing CPR can be a very difficult process. You may want to talk things over with your medical team, your specialist nurses (Macmillan nurses), or spiritual carers such as your chaplain or priest.

Some people feel they cannot make the decision themselves and may want their doctor to make it for them.

You can certainly express your views about CPR and request that it will or will not be attempted. If your doctor feels that it is unlikely to be successful, and does not believe that CPR should be attempted, you can arrange for a second medical opinion from another senior doctor. Your doctor can advise you about seeking a second opinion (as can your GP).

The healthcare team will take into account your wishes about CPR. A senior doctor can ultimately decide not to attempt CPR, however, if in their clinical judgement it is not appropriate.

In some situations you may not be able to make a decision about CPR, for example if you are unconscious, or too drowsy from medication.

In this situation, doctors would usually discuss CPR with your next of kin or other appropriate relatives. They would try to get an idea about your probable views on CPR from people who know you. Normally you would need to give your permission before medical staff can discuss any details regarding your medical condition with your family.

In England, Wales and Northern Ireland, although relatives can give their view, any final decision about CPR would be the responsibility of the doctor when the patient is unable to make the decision.

In Scotland, anyone over the age of 16 is allowed to nominate a proxy decision maker, should they become unable to make the decision themselves. The nominated person must be consulted about treatment decisions, but cannot demand treatment that the doctors feel is unreasonable.

The doctor will inform other members of the healthcare team that CPR has been discussed with you and what decision has been made. This information is confidential and will only be discussed amongst those caring for you, such as the doctors and the nursing team.

The decision will also be written clearly in your medical and nursing notes (but will not be documented in the nursing notes at the end of your bed).

If the decision has been made not to attempt CPR this is written as a 'do not attempt resuscitation' (DNAR) order or 'not for resuscitation' (NFCPR). In the medical notes the doctors will usually document a planned review date, so that this issue is reviewed on a regular basis.

If a person leaves the hospital ward (for example, for an x-ray) they will usually take their medical notes with them. Many hospitals have a system whereby a sticker on the outside of the medical notes indicates that CPR should not be attempted. This is to ensure that all health professionals are aware of the person's 'resuscitation status'.

As well as the 'sticker' system, hospitals aim to have good communication so that staff in other departments are aware if CPR is not to be attempted. This covers the situation when a person leaves the ward but does not have their notes with them.

A person may wish to discuss their concerns regarding CPR before they are discharged home. It is important to bear in mind that in the community there is no specialist team or equipment at hand should a cardiopulmonary arrest happen. In that situation, a 999 call would need to be made.

If it has been decided that a person is not for CPR and an ambulance is called, the ambulance crew would always attempt CPR unless there is clear documentation stating the 'do not attempt resuscitation' order, which needs to be officially approved by a doctor.

You are free at any time to change your mind about whether or not CPR should be attempted. If you do change your mind, it is important that you tell a member of your healthcare team, so that you can discuss this with them. If necessary, your medical notes can be changed.

Some people with cancer may wish to make a choice about whether they want CPR to be attempted in the months or years ahead. They can document their decision in a living will (also known as an advanced directive) so that, should the situation ever arise, their wishes are already known. A copy of the living will can be put into the person's medical notes.

Any decision you make about CPR will not affect any other care or treatment that you receive.

Each time you are admitted to hospital one of the doctors involved in your care will review your CPR status and discuss this with you. This is necessary because your medical condition and your views may change.

Take time when considering the issue of CPR and ask your medical team if you are unsure. It may help to ask your family and friends for their opinions, as well as writing down a list of questions to discuss with your doctor, before making your decision.

This section has been compiled using information from a number of reliable sources including:

• Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, Resuscitation Council (UK ) and the Royal College of Nursing. 2007.

For further references, please see the general bibliography.