1. ST1&2 DNACPR - Key Issues & Approach

2. DNACPR – Key Issues Consider -The fundamentals -The framework -The decision making process -The patient / family view -Legal aspects

3. DNACPR – Fundamentals The decision to offer CPR is a medical one Nothing to do with ‘quality of life’ If CPR is likely to be futile do not offer it

4. DNA CPR – Framework Is the patient at risk of a cardiopulmonary arrest? Decision making -CPR is unlikely to be successful due to: -The likely outcome of successful CPR would not be of overall benefit to the patient decided with patient decided with legally appointed......basis of overall benefit... – CPR is not in accord with a valid advance healthcare directive/decision (living will) which is applicable to the current circumstances

5. DNA CPR – Decision making Is CPR realistically likely to succeed? – What do we mean by ‘success’? – Population that we are considering – Facilities available – People available

6. DNACPR – patient / family / legal issues Patient / family view is only relevant if CPR is a treatment option If success anticipated – discussion needed If success not anticipated – inform patient Relatives should not be asked to ‘decide’ unless patient lacks capacity & legally empowered to do so Communicate sensitively!

7. DNACPR – Approach Consider – When you have done this What worked well? What didn’t?! – How to raise the subject – When to raise the subject – Practicalities

8. DNACPR – Before any discussion Your knowledge of -Illness trajectory & prognosis -Patient awareness & insight Discussion -Benefit / burden -Timing

9. CPR – Decision What you think / what patient wants – You think possible / patient doesn’t want CPR Simple – You think possible / patient wants CPR Complicated – You think futile / patient doesn’t want CPR Simple – You think futile / patient wants CPR Complex

10. Introducing the subject of DNACPR Communication Breaking bad news – Narrowing the information / knowledge gap – We know something we think they need to know! – How much do they actually know? – How much more, if any, do they want to know – When do they want to know – Who do they want to tell them

11. The ‘bad’ news What we feel we need to cover – Whether CPR should be offered or not – If ‘futile’ patient / loved ones need to know this – If ‘not futile’ then we need to know what patient wants

12. Getting CPR raised By patient and carer – Spontaneously – Prompted Another professional e.g. the hospital said… ‘My Thinking Ahead & Making Plans’

13. Getting CPR raised By us – Gauge patient understanding Illness Trajectory Future

14. Getting CPR raised By us (continued) – Planning ahead (ACP!) How do you feel you are doing? Where would you like to be cared for? And if things got worse…? How do you see the future? Are there any things you’d like to avoid? Etc etc etc What if there was a sudden change in your condition? What if your heart was to stop? – Introduce CPR

15. CPR – the subject matter General – What it means Life saving intervention v. Allow a natural death – Possible outcomes / uncertainties Success / failure / quality of life – Whether ‘people’ would wish it Individual – In your case… ‘Fine line’ – Awareness raising, BUT – Clinical decision has already been made

16. What DNACPR is not about Anything other than CPR Any other treatments e.g. antibiotics Feeding Fluids Highlight everything else that we can still do

17. Patient centred supportive care What’s the most important thing in your life right now? What helps you keep going? How do you see the future? What is your greatest worry or concern? Are there ever times when you feel down? If things get worse, where would you like to be cared for? Professor Scott Murray, University of Edinburgh

18. DNA CPR – Practicalities Completing the DNACPR form Where should form be kept When to update form Patient transfer(!)

19. DNA CPR – Practicalities Communication – Patients home Patient Family / loved ones OOH Services Scottish Ambulance Service Others?

20. Thoughts / Comments / Questions?