Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) NHS Scotland Policy

Objectives Key points of the policy Framework for resuscitation decisions The DNACPR form Patient Information Leaflet

The Policy: Based on integrated DNAR policy implemented by NHS Lothian In line with revised Joint statement on CPR decisions by BMA/RCN/RC(UK) 2007 and GMC guidance (2010) Fully integrated between Primary and secondary care services Supported By Scottish Ambulance Service Recommended in “Living and Dying Well” the Scottish Government Action Plan for Palliative and End of Life Care Requested by Public Audit Committee

Why does it have to be integrated? Example 1: Patient with DNACPR form whilst in-patient discharged home to die Patient died that evening more suddenly than expected Family panicked – 999 called Ambulance crew attempted resus Police attended, confiscated patients drugs, body removed to police mortuary GP from out-of-hours service attended but unable to prevent this

Why does it have to be integrated? Frequent examples of: Inappropriate resus attempts Nursing staff putting out 2222 call when they know patient was expected to die Inconsistent and varied documentation causing confusion DNACPR decisions delayed in futile clinical situations because it hasn’t been discussed Doctors offering CPR as a choice to dying patients (or their relatives) where it would clearly be unsuccessful Medical staff asking relatives to make DNACPR decisions

Hospital issues: Increased movement of staff and patients between hospitals Patients being looked after by increased numbers of different staff (shifts, teams, hospital at night etc.) DNACPR documentation deferred due to belief that all patients must be asked about DNACPR decisions

Community issues: Existence of DNACPR order needs to be communicated to GP, DN, care home staff and OOH on discharge Existence of DNACPR order at home needs to be communicated to hospital/hospice team on admission GPs often unsure when to sign DNACPR orders For DNs, Marie Curie nurses and other experienced palliative care nurses a default of attempting CPR in the absence of a DNACPR form is impractical

Ambulance issues: Existence of DNACPR form needs to be communicated to ambulance personnel Mechanism needed for informing emergency and OOH service about DNACPR order Clear instructions are needed about what to do in the event of death in transit Who to contact Where to take the patient

NHS Scotland DNACPR policy: Single, high visibility, widely recognisable, self-explanatory DNACPR form designed to follow the patient and contain all info needed by community, acute and ambulance services Decision making framework to assist medical and nursing staff in all settings Patient information booklet to improve patient and relative awareness, and assist discussions

Picture of framework Available in all areas Quick reference of the policy Extra guidance notes on the reverse Picture of framework

When do you need to make a decision about resuscitation ? Can a cardiac or respiratory arrest be anticipated for this patient? NO: No further thinking about DNACPR is required Do not burden the patient with having to make a decision about resuscitation In the unlikely event they have a cardiac arrest attempt resuscitation unless it clearly would not work

When do you need to make a decision about resuscitation ? Can a cardiac or respiratory arrest be anticipated for this patient? YES: Are you as certain as you can be that CPR could realistically have a successful outcome (in terms of medically sustainable life) Yes decision to have DNACPR order rests with competent patient Sensitive exploration of patients wishes if appropriate Set in context of patient’s illness, end of life care wishes and likely outcome of “successful” CPR

Explanation of “successful CPR” should be realistic - remember patient and family perception of it is not! Will it work and how will I be if it works? Patients/relatives – yes definitely …with a cup of tea afterwards to help recover to full health (TV survival to hospital discharge = 63%) Doctors/Nurses – possibly (Drs overestimate prognosis by factor of 5 when discussing with patients/relatives) Reality – probably not / definitely not (survival to hospital discharge 13-14%)

If CPR might realistically be successful but patient lacks capacity to make a decision A decision about what will be of overall benefit for the patient must be made by the clinical team or legally appointed welfare guardian A “benefit vs burden” judgement must be made about CPR and its likely outcome for that patient Relatives must not be made to feel that they are making the decision but can offer opinions about what the patient would have wanted. The discussions and decision-making process must be documented

When do you need to make a decision about resuscitation ? Can a cardiac or respiratory arrest be anticipated for this patient? YES: Are you as certain as you can be that CPR could realistically not have a successful outcome ( in terms of medically sustainable life) Yes decision to have DNACPR order rests with senior clinician (Dr or nurse) responsible for the patient Actively seek opportunities to sensitively make patient aware of this as part of information about illness and prognosis DNACPR form can be completed without discussing with patient

Do I need to discuss DNACPR when CPR will not work? “If CPR would not restart the heart and breathing it should not be attempted” “In most cases the patient should be informed but for some patients, for example those who are approaching the end of their life, such information will be unnecessarily burdensome and of little or no value” Decisions relating to CPR – a joint statement from the BMA, RC(UK) and the RCN Oct 2007

Nursing Roles & Responsibilities Taking clinical responsibility for a DNACPR decision In certain settings an experienced nurse may be the most senior responsible clinician decision for the patient (eg nurse consultants or senior clinical nurse specialists).  Such a decision may be recorded on a DNACPR form and signed by the experienced nurse.

Nursing Roles & Responsibilities Discussing DNACPR Experienced nurses may be best placed to initiate this conversation with a patient but any nurse may also have an important role in supporting the patient during and after these discussions.  Clinical judgement at the time of cardiopulmonary arrest Where there is no DNACPR form and the patient has a cardiac arrest, experienced nursing staff can decide not to attempt CPR on a patient who is clearly in the terminal phase of an illness.

Picture of DNACPR form (front) Communication tool (Decision should still be clearly documented in notes) Clearer instructions Only need to complete one of the three boxes File in front of notes No form does not automatically mean CPR must be attempted Picture of DNACPR form (front)

Review when clinical responsibility changes and at individualised clinically appropriate intervals Complete “Ambulance Crew Instructions” before transfer If the form is going home with the patient it must be the original Inform GP / community nurses / OOH before discharge home If form not going to patients home but patient still DNACPR send to GP

DNACPR patients being discharged home: Review if DNACPR decision is still valid Clinical team should decide whether it is of benefit for patient to have DNACPR form at home likelihood of sudden death importance of ensuring dignified, peaceful, natural death where possible If appropriate; sensitive discussion is needed to explain form’s positive role to patient and family Unscheduled Care Service should be informed via patient’s GP (electronic Palliative Care Summary – ePCS) and/or special notes system THE FORM SHOULD NEVER BE SENT HOME WITH A PATIENT IF THEY ARE NOT AWARE OF IT’S EXISTENCE

If form isn’t discussed with patient/relative…. WIFE’S FURY AT ORDER TO ENSURE NATURAL, PEACEFUL AND DIGNIFIED DEATH AT HOME……….. ……doesn’t have quite the same headline impact!!!

ePCS - What is it? An electronic Palliative Care Summary An extension to Emergency Care Summary (ECS) & GPs’ palliative care registers - Gold Standards Framework Scotland (GSFS) For use both In Hours & OOH Allows GPs & Nurses to record in one place - Diagnosis, Rx, Pt Understanding & Wishes, Anticipatory Care Plans, review dates, DNACPR decision etc ePCS replaces current faxed communications Info available to NHS24, paramedics, A&E, Acute Receiving Units etc 23

Example of Mobile ePCS information 24

DNACPR patients being discharged home cont: If not felt appropriate for the patient to have a DNACPR form at home but CPR would clearly be futile the GP should be informed - they may then choose to discuss the form at a more appropriate time No need to “reverse” the DNACPR form prior to discharge - document why it wasn’t sent with the patient and either file original copy in notes or send to GP NB. IF A DNACPR PATIENT IS AT HOME WITHOUT THE FORM THERE IS ALWAYS A RISK OF INAPPROPRIATE PARAMEDIC AND POLICE INTERVENTION

Patient with DNACPR order being transferred by Scottish Ambulance Service: Ambulance control must be told if there is a DNACPR order in place for the journey The ambulance section must be completed and shown to the crew prior to transfer If the form is going home with patient the crew must be told that the patient and family are aware of the form before they are given the original copy If original form being kept or sent to GP – the crew should be shown the original form prior to the journey so they are certain of the information.

When no DNACPR decision has been made and the patient arrests: It is presumed staff would attempt resuscitation However, it is unlikely to be considered reasonable to resuscitate a patient who is clearly in the terminal phase of illness Experienced medical or nursing staff are therefore not obliged to initiate resuscitation in a patient who’s death is clearly expected

Patient Information Booklet Based on joint BMA, RCN, RC(UK) document Available to all clinical staff Used to improve patient and relative awareness and assist discussions Worth reading if you don’t know where to start with DNACPR discussions

Remember: DNACPR Orders only refer to cardiopulmonary resuscitation, not to any other treatments. Unexpected deterioration should always be assessed and managed appropriately irrespective of DNACPR status

Any Questions ?