1. Do Not Attempt Cardio- Pulmonary Resuscitation (DNACPR) Dr Linda Wilson Consultant in Palliative Medicine Airedale/Manorlands

2. Both right - knowing when to do which and making it happen – that’s our challenge!

3. If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful, making and recording an advance decision not to attempt CPR will help to ensure that the patient dies in a dignified and peaceful manner. It may also help to ensure that the patient’s last hours or days are spent in their preferred place of care by, for example, avoiding emergency admission from a community setting to hospital. GMC ‘Treatment and Care Towards the End of Life’ 2010

4. This session: Background Background When/who to discuss with When/who to discuss with How to record How to record How to discuss- DVD How to discuss- DVD

5. Useful Guidance 2007: Joint guidance on DNACPR from UK Resus. Council, BMA and RCN 2007: Joint guidance on DNACPR from UK Resus. Council, BMA and RCN 2007: Mental Capacity Act 2005 (MCA) Code of Practice 2007: Mental Capacity Act 2005 (MCA) Code of Practice

6. 2010: Treatment and care towards the end of life: good practice in decision making. GMC 2010:NHS Bradford & Airedale Joint Policy

7. Bottom line Resuscitation should be attempted in every patient who wishes for this to happen and for whom it has a reasonable chance of success Resuscitation should be attempted in every patient who wishes for this to happen and for whom it has a reasonable chance of success Cardiac arrest is the final event in all deaths, inappropriate CPR may subject people to an undignified death Cardiac arrest is the final event in all deaths, inappropriate CPR may subject people to an undignified death It is crucial to identify those patients with capacity who state clearly that they do not want CPR to be attempted It is crucial to identify those patients with capacity who state clearly that they do not want CPR to be attempted

8. Does CPR work? Many hospital studies but not standardised Many hospital studies but not standardised Overall around 10-20% survive to leave hospital Overall around 10-20% survive to leave hospital Pneumonia, hypotension, renal failure, cancer, AIDS, sepsis, dementia, creatinine > 130 μmol/L, CVA, CCF all been associated with a decreased likelihood of survival Pneumonia, hypotension, renal failure, cancer, AIDS, sepsis, dementia, creatinine > 130 μmol/L, CVA, CCF all been associated with a decreased likelihood of survival Public estimates of survival in the region of 50%

9. Clinical experience, supported by the evidence in the literature, would suggest that CPR in patients with advanced, progressive cancer (and other advanced progressive conditions) who have poor performance status, and irreversible medical problems, can be classified as physiologically futile according to any definition. Suzanne Kite THE LANCET Oncology Vol 3 October 2002 Summary

12. When to consider a DNACPR decision Patients with an advanced life threatening illness if you would not be surprised if they were to die within the coming 12 months (?nursing homes) As part of any advanced care planning discussions At a patients request

13. DNACPR decision making- 4 scenarios  Futile  Capacity  Lack Capacity  May work  Capacity  Lack Capacity

14. you are NOT OBLIGED to discuss it with patients or their families, HOWEVER……. you are NOT OBLIGED to discuss it with patients or their families, HOWEVER……. You must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made You should not withhold information simply because conveying it is difficult or uncomfortable If you conclude that the patient does not wish to know about or discuss a DNACPR decision, you should seek their agreement to share with those close to them, the information they may need to know in order to support the patient’s treatment and care 1. Futile with Capacity

15. 2. Futile Lack Capacity You should inform any legal proxy and others close to the patient about the DNACPR decision and the reasons for it.

16. If you think CPR may be successful… If patient has capacity If patient has capacity You should offer opportunities to discuss whether CPR should be attempted

17. Patient who lack capacity and for whom CPR may work Do they have an ADRT? Do they have an ADRT? Do they have a legal proxy? Do they have a legal proxy? Make a best interests decision in conjunction with family Make a best interests decision in conjunction with family their role is to advise you and the healthcare team about the patient. You must not give them the impression that it is their responsibility to decide. IMCA if suitable family/others or legally appointed proxy to consult IMCA if suitable family/others or legally appointed proxy to consult

18. How to record The new form ! The new form !

20. Process of transfer from one setting to another: Review DNACPR decision prior to transfer Review DNACPR decision prior to transfer Original form to be sent with patient Original form to be sent with patient Inform all relevant professionals (template) and handover forms Inform all relevant professionals (template) and handover forms

21. Discussing CPR May happen naturally as part of a general discussion Ensure comfort and privacy; sit down next to the patient. Ask if family members or others should be present. Introduce the subject with a phrase such as: I’d like to talk with you about possible health care decisions in the future.

22. 2. What does the patient understand? An informed decision about DNR status is only possible if the patient has a clear understanding of their illness and prognosis. Ask an open-ended question to elicit patient understanding about their current health situation. Consider starting with phrases such as: What do you understand about your current health situation? or What have the doctors told you about your condition? If the patient does not know/appreciate their current status this is time to review that information.

23. 3. What does the patient expect? Ask the patient to consider the future. What do you expect in the future? or What goals do you have for the time you have left—what is important to you? Most patients with advanced, life limited disease use this opening to voice their thoughts about dying—typically mentioning comfort, family, and home, as their goals of care. If there is a sharp discontinuity between what you expect and what the patient expects, this is the time to clarify.

24. Summarise So what you’re saying is, you want to be as comfortable as possible when the time comes What you’ve said is, you want us to do everything we can to fight, but when the time comes, you want to die peacefully. We have agreed that the goals of care are to keep you comfortable and keep you at home

25. We will continue maximal medical therapy to meet your goals. However, if you die in spite of everything, we won’t use CPR to bring you back. It sounds like we should move to a plan that maximizes your comfort. I will write an order in your medical and nursing records that if you die, no attempt to resuscitate you will be made, is this ok with you?

26. Persistent requests for CPR— Understanding Why? “Can you explain why you feel that way?” Inaccurate information about CPR Use information leaflet Hopes, fears and guilt. "This decision seems very hard for you." "I want to give you the best medical care possible; I know you still want CPR, can you tell me more about your decision?"

27. Managing Persistent Requests for CPR Consider obtaining a second opinion Don’t complete the form and return to the discussion another time

28. DVD DVD

29. Questions / Discussion Questions / Discussion