Do Not Attempt Cardio Pulmonary Resuscitation – (DNACPR) and Mental Capacity – (MCA) Completion Tracy Reed Education Facilitator for End of Life Care EPUT

What Will Be Covered Burdens and risks of CPR Likelihood of success of CPR Burdens and risks of CPR Who should we be talking to about DNACPR Barriers to making DNACPR decisions and Legal Factors How to start the conversation Mental Capacity and Best Interest Decisions

Likelihood of success of CPR Dependent on: The cause of cardiac or respiratory arrest The underlying health of the victim The time elapsed between the arrest and CPR The technique used by the person performing CPR Where the arrest takes place Percentage outcomes: 2% to 30% effectiveness when administered outside of the hospital 6% to 15% for hospitalized patients Less than 5% for elderly victims with multiple medical problems

GMC - burdens and risks of CPR Rib fracture and damage to internal organs Hypoxic brain damage Increased physical disability Undignified and traumatic death Family not aware of risk of death

Who should we be talking to? Patients with terminal illness Patients with multiple pathology Patients at advanced age As part of advance care planning in patients with dementia

Barriers to Making DNACPR Decisions and Legal Factors GMC 2010 You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team Addenbrookes v Tracey When patients challenge our decision they have the right to a second opinion IMCA involvement needed if no significant other Medical decision and BMA Guidelines: Decisions not to resuscitate should depend on: The likely clinical outcome - likelihood of success and overall benefit from a successful resuscitation The patient’s known, or ascertainable, wishes The patient’s human rights The right to life The right to be free from degrading treatment Views of all members of the medical and nursing team including people close to the patient should be sort

How to start the conversation Not in isolation Start with what you are going to do first Discuss patients understanding of their condition and assess their capacity Any advance directives/ community forms? If lack capacity seek opinion of NOK in same way

Specific Outcome in the Context of The Mental Capacity Act (2005) Advance Care Planning Advance Statement Decisions To Refuse Treatment Lasting Power Of Attorney

Best Interest Decision Making The Mental Capacity Act (MCA) states that if a person lacks mental capacity to make a particular decision then whoever is making that decision or taking any action on that person’s behalf must do this in the person’s best interests. This is one of the principles of the MCA. A lack of capacity must have been established as a result of assessing the person’s capacity in accordance with the MCA and its Code of Practice.

Best Interest Where a decision is about treatment or resuscitation,  a doctor has to act as a decision maker. The doctor has to follow any advance care plan and should consult with all relevant people (as practicable) who could be interested in the specific decision (carers, family members,  friends, other health care professionals, social care, IMCA, LPA etc.) To enable them to understand patients beliefs, wishes and views even if the patient now lacks capacity. It is best practice to record MDT involvement in these discussions. Record discussions in the medical notes and document on the DNACPR form as your evidence of how the decision is made.

Decision under MCA If you are making the decision under the Mental Capacity Act you must take the above steps, amongst others and weigh up the factors in order to determine what is in the person’s best interests. For more information you should refer to the Code of Practice. MCA forms and information can be accessed via: Essex safeguarding Adult Board’s website: http://www.essexsab.org.uk/en-gb/professionals/mcaanddols.aspx You can also contact your: Adult Safeguarding Team West Essex CCG – 01992 566120  

Princess Alexandra Hospital DNACPR Process and Treatment Escalation Plans –TEP Update Sarah Jones, Ceilings of Treatment Nurse Advisor Matthew Ibrahim, Resuscitation Officer

‘How people die remains in the memory of those who live on’ Dame Cecily Saunders Founder of the Modern Hospice Movement

SURVEY

resources Royal College of General Practitioners (RCGP): End of life care GMC: Treatment and care towards the end of life: good practice in decision making Gold Standards Framework (GSF) http://www.goldstandardsframework.org.uk/ Prognostic Identification Guidance http://www.goldstandardsframework.org.uk/pig Essex safeguarding Adult Board’s website: http://www.essexsab.org.uk/en-gb/professionals/mcaanddols.aspx End of Life Care for All Dying Matters Information for patients  Planning for Your Future Care NHS Choices: End of life care NHS Choices: Carers and end of life care East of England Patient information Leaflet Training and development  e-ELCA training in advance care planning; assessment; communication; symptom management, comfort and well-being East of England DNACPR e-learning Dying Matters DNACPR http://talkcpr.wales

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