1. The NHS Scotland Integrated DNACPR policy
Dr Juliet Spiller
Consultant in Palliative Medicine
Marie Curie Hospice Edinburgh

2. Aim of CPR – achieve sustainable life
CPR = total opposite of traditional idea of a “good death” (peaceful, dignified, comfortable, family presence etc)
What is a DNACPR decision?
CPR is not to be attempted when patient dies
CPR won’t achieve sustainable life (Clinical)
The burden of CPR Rx and likely outcome is such that the patient doesn’t want CPR attempted (overall benefit)
Protection for patients from aggressive, undignified, unnatural death – not a possible Rx being withheld
What is a DNACPR form?
Communication tool for that decision

3. Why do people get so upset about DNACPR orders?
Common misunderstandings
“Not for CPR” means not for anything
“being left to die”
“being written off”
CPR is nearly always successful
TV/media survival = 64%!
Successful CPR has no harmful effects
Wake up smiling and have a cup of tea

4. Jean – 78yrs old with moderately severe dementia, emphysema, diabetes and osteoporosis
- Admitted to care home 2yrs ago following the death of her husband and an unsettled 2 months living with her only daughter.
- Gradual functional and cognitive decline, worsening eyesight.
- Very unsettled by 2 recent hospital admissions for treatment of chest infections
- Sudden collapse on a Friday evening while staff were helping her off the toilet – acutely breathless and distressed
- 999 call. No pulse by the time paramedics arrived. CPR attempted. PLE after 20 mins (and rib fractures)
- Police arrived, LUCS GP called but unable to provide death certificate
- Jean’s body removed to police mortuary until Monday when own GP provided death certificate

5. May 2006 NHS Lothian implementation of UK’s first fully integrated DNAR policy
DNAR form – all healthcare settings, home, care homes, ambulance crews, police
Decision-making framework
Patient info booklet
Revised 2007
Policy shared with individuals from SHBs and English SHAs and national organisations (BMA, GMC, Marie Curie Cancer Care, Macmillan OoH Group, National Council for Palliative Care, Scottish Partnership for Palliative Care)
Aug 2008 Living and Dying Well action point (SAS End of Life Care Plan)
Jan 2009 Public Audit Committee request for national consistent DNAR policy

6. NHS Scotland DNACPR policy
Consensus by national steering group
Single NHS Scotland policy & documentation
“DNACPR” rather than DNAR
Emphasising best practice in CPR decision-making (nothing new)
Providing framework for improved communication of DNACPR decisions (new)
Boards to implement by October 1st

7. NHS Scotland DNACPR policy
Does not make clinical decision-making easy
Does not make the communication issues easy
……that’s just part of the job!

8. How does this apply to care homes?
Requirement to have a policy about resuscitation decisions already exists (blanket policy of non-resuscitation is unlawful and unethical)
An opportunity to engage with a Scotland-wide initiative
Easy link with existing communication systems (eg OOH special notes / ePCS)
Immediately recognisable to GPs, OOH services, SAS, police who may attend residents in the home
Transferable to acute hospitals
Patients may be discharged to you with these forms

9. Consistent communication tool (Decision process and discussions should still be clearly documented in notes)
Must be immediately accessible
No form does not automatically mean CPR must be attempted
Only refers to CPR

10. How does this benefit residents and their families?
Reassurance that a treatment that will not work, or that is not wanted, will not be attempted.
Reassurance that death will be as natural, dignified and peaceful as is possible even if the death is sudden
…………BUT……….DNACPR should not be addressed in isolation

11. A good idea applied in the wrong way….can become a bad idea!

12. Anticipatory Care Plans - core info.
Diagnosis. Welfare attorney/guardian
What can be anticipated for this person and how should that be managed?
Views and advance decisions about escalation of treatment / place of care / place of death
ITU
HDU
DNACPR
IV treatment
oral treatment
comfort measures only

13. DNACPR in practice in Care homes
Part of anticipatory care planning – evolving and individualised process
Not about asking all residents if they want resuscitated
Not about asking family to make a decision (where CPR can be offered) unless they are legally appointed healthcare proxy
Clarify prior to transfer / admission if possible
Ensure all staff are aware DNACPR decision is only about CPR – any deterioration should be assessed and managed appropriately

14. DNACPR in practice in Care homes
Where CPR clearly won’t work it can’t be offered – clinical decision
Responsibility for decision – most senior clinician with clinical responsibility for the patient = GP / Senior nurse (d/w your GPs)
Good practice to sensitively inform resident as part of ACP information
Where patient lacks capacity relatives should be informed of ACP information including DNACPR
Such discussions can be nurse / carer led (d/w your GPs)

15. Continued reluctance for DNACPR discussions
What if they get upset….?

16. To discuss or not to discuss….?
Timing – it’s not just about CPR outcome
Awareness of palliative phase of illness
Any indication of willingness for advance care planning conversations?
Is talking about death something this patient can get their head around without harmful distress at the moment (or ever)?
“Benefit vs. burden” balance of the discussion
Different for patients at home
For some patients it will never be the right thing
For many patients it is a relief and a reassurance

17. Informing relatives Need patient consent to discuss with relatives
But needn’t always be explicitly for DNACPR
Where the patient lacks capacity “you should inform any legal proxy and others close to the patient of the DNACPR decision and the reasons behind it”
GMC 2010

18. Training Information and educational resource available on website
Awareness sessions run locally – contact resuscitation department
Communication aspects of DNACPR discussions
DVD available via website
Facilitated sessions may be organised through local palliative care service

19. Key questions for groups
How can we engage with the GPs that support the care home to ensure best practice around DNACPR decision-making?
How can we engage with the acute hospitals to ensure best practice on admission to and discharge from acute hospitals to care homes?
How can we empower staff to understand and address DNACPR decision-making in the context of anticipatory care plans as standard best practice for residents?