Do Not Attempt Cardiopulmonary Resuscitation DNACPR NHS Scotland

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) NHS Scotland Policy (2016) 1

• Objectives – Key points of the policy – Framework for resuscitation decisions – The DNACPR form – Patient Information Leaflet 2

The Policy: • Original policy implemented in 2010 • Light-touch review in 2015/16 • In line with revised guidance from BMA/RCN/RC(UK) 2016 and GMC guidance (2010) • Fully integrated between Primary and secondary care services • Supported By Scottish Ambulance Service • Supported by Police Scotland Crown Office & Procurator Fiscal Service 3

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 4

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 5

Hospital issues: • Increased movement of staff and patients between hospitals • Patients being looked after by increased numbers of different staff (shifts, teams, agency, hospital at night etc. ) • DNACPR documentation deferred due to misunderstandings about the communication of DNACPR decisions 6

Community issues: • Existence of advance DNACPR decision needs to be communicated to GP, DN, care home staff and OOH on discharge and added to Key Information Summary (KIS) • Existence of advance DNACPR decision at home needs to be communicated to hospital/hospice team on admission • For DNs, Marie Curie nurses and other experienced community nurses a default of attempting CPR in the absence of a DNACPR form is impractical. 7

Ambulance issues: • Existence of DNACPR form needs to be communicated to ambulance personnel • Clear instructions are needed about what to do in the event of death in transit – Who to contact – Where to take the patient • DNACPR information may be accessible by ambulance crews via KIS 8

NHS Scotland DNACPR policy: • Single, high visibility, widely recognisable, selfexplanatory 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 9

• Available in all areas Picture of framework • Quick reference of the policy • Extra guidance notes on the reverse 10

When do you need to make a decision about resuscitation ? • Is cardiac or respiratory arrest a clear possibility for this patient? NO: – No further thinking about DNACPR is required – Do not burden the patient with having to make a decision about CPR unless they express a wish to discuss it – In the unlikely event they have a cardiac arrest attempt resuscitation unless it clearly would not work 11

When do you need to make a decision about resuscitation ? • Is cardiac or respiratory arrest a clear possibility for this patient? YES: – Is there a realistic chance that CPR could be successful ie achieve sustainable life for the patient? YES: – decision to have DNACPR order rests with competent patient – Sensitive exploration of patients wishes if appropriate – Discuss in context of patient’s illness; goals of care, realistic treatment choices, and end of life care wishes; and likely benefits and burdens of “successful” CPR 12

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 – brutal treatment, high harm risk if successful – (survival to hospital discharge 15 -20% but far lower or 0% for frailty, advanced irreversible illness etc 13)

If CPR might 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 with legal welfare attorney/guardian • A “benefit vs burden” judgement must be made about CPR and its likely outcome for that patient • Those close to the patient must not be made to feel that they are responsible for the decision but must be involved in any overall benefit decision and enabled to offer opinions about what the patient would have wanted. • The discussions and decision-making process must be documented 14

When do you need to make a decision about resuscitation ? • Is cardiac or respiratory arrest a clear possibility for this patient? YES: – Is there a realistic chance that CPR could be successful ie achieve sustainable life for the patient? NO: – The DNACPR decision (CPR would not work) rests with senior clinician (Dr / Nurse) responsible for the patient – the presumption is that this information will be shared with the patient sensitively as part of discussions about their clinical situation, goals of care and end of life care wishes – DNACPR form can be completed and process and 15 discussions must be clearly documented

Do I need to discuss DNACPR when CPR will not work? “Making a decision not to attempt CPR that has no realistic prospect of success does not require the consent of the patient or of those close to the patient. ” “In most cases people should be informed, but for some, for example those who know that they are close to the end of their life, such information may be so distressing as to cause the person to suffer physical or psychological harm. ” Decisions relating to CPR – guidance from the BMA, RC(UK) and the RCN (2016) 16

Nursing Roles & Responsibilities • Taking clinical responsibility for a DNACPR decision – In certain settings an experienced nurse may be the most senior responsible clinician for the patient during a care episode (eg nurse consultants or senior clinical nurse specialists). – Where the responsibility as senior clinician for the patient is agreed and understood by the multidisciplinary team an advance DNACPR decision may be recorded on a DNACPR form and signed by the experienced nurse. 17

Nursing Roles & Responsibilities • Discussing CPR as part of exploring goals of care and end of life care wishes – 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 initiate CPR where it is clear that the patient is in the advanced final stages of a terminal illness and it is certain that death was expected to be imminent and unavoidable. 18

• Picture of DNACPR form (front) • Communication tool not legal document (Decisionmaking process and discussions must be clearly documented in notes) • File in front of notes (immediate visibility & access in emergency) • No form does not automatically mean CPR must be attempted 19

• Review when clinical responsibility changes and at individualised clinically appropriate intervals • Complete “Communication with Ambulance Crew ” before transfer • If the form is going home with the patient it must be the original • Prompt GP to update KIS on patient’s discharge. Where the discussion has not happened to allow the form to go home with the patient the GP must be made aware of the 20 KIS reason so this can be put on the

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 • Ensure patient’s GP is informed so that the Key Information Summary (KIS) can be updated • THE FORM SHOULD NEVER BE SENT HOME WITH A PATIENT IF THEY ARE NOT AWARE OF IT’S EXISTENCE 21

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!!! 22

Key Information Summary (KIS) What is it? • An extension to Emergency Care Summary (ECS) & electronic Palliative Care Summary – 2 -3% of GP patients at present • For use both in Hours & OOH - ECS / KIS replaces faxed communications • Info available to NHS 24, paramedics, A&E, Hospitals via Portal or TRAKcare • Useful / helpful for: – Patients with long term conditions, in particular if they take multiple medications and attend multiple specialist clinics – Patients who are likely to present to unscheduled care at the weekend or out of hours – Patients who may find it difficult to communicate in an emergency (for example, people who have communication or memory problems, mental health issues or learning disabilities) – Patients with palliative care needs 23

KIS - What information might it contain? • Past Medical History (High-priority read codes are automatically included) • Baseline functional and clinical status, including capacity • Triggers for deterioration • Current care needs and arrangements • Emergency Contacts and Next of Kin Details • How far to escalate care • Preferred place of care, and final care, other specific patient/carer wishes • Palliative care information • Legal issues such as power of attorney • DNACPR status • Special alerts – for example around staff safety 24

Example of view of the KIS in Hospital Attached to ECS medications is the following ‘abbreviated’ version of the KIS: • Includes DNACPR, PMH, Special Note/ ACP DNACPR/ CYPADM Form in place? PMH SPECIAL NOTE/ACP NOTE & DATE

DNACPR patients being discharged home cont: • Where a conversation about the form has not been possible during the admission, revisit and review the reasons for this. • If it remains impossible to sensitively explore goals of care and realistic treatment options with the patient without causing them physical or psychological harm, document the reasons and inform the GP why the DNACPR form is not being sent home with the patient. The GP may then choose to discuss the form at a more appropriate time • Do not “reverse” the DNACPR form prior to discharge, either mark and file original copy in notes or mark and place photocopy in notes for audit and send original form to GP NB. IF A DNACPR PATIENT IS AT HOME WITHOUT THE FORM THERE IS ALWAYS A RISK OF INAPPROPRIATE 26 PARAMEDIC AND POLICE INTERVENTION

Patient with DNACPR decision being transferred by Scottish Ambulance Service: • Ambulance control must be told if there is a DNACPR decision in place for the journey • The ambulance section of the DNACPR form must be completed and shown to the crew prior to transfer • If the form is going 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 the form is not being sent with the patient the crew should be shown the original form and/or given verbal instructions prior to the journey so they are certain of the information. 27

When no DNACPR decision has been made and the patient arrests: • It is presumed staff would initiate CPR • However, it is unlikely to be considered reasonable to initiate CPR – when a patient dies who was clearly in the advanced stages of a terminal illness where death was imminent and unavoidable – Where signs of irreversible death are present eg rigor mortis • In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies. “Decisions relating to CPR” – guidance from the BMA, RC(UK) and the RCN 2016 28

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 29

DNACPR Education Resources • ACP toolkit and DNACPR information www. palliativecareinpractice. nes. scot. nhs. uk • Video developed for online hospital consultants’ module – open access http: //www. mystar. org. uk/dnacpr/start. asp • Online module for Foundation Year Doctors www. nhseportfolios. org • Communication aspects of DNACPR discussions videos available via palliative care in practice website www. palliativecareinpractice. nes. scot. nhs. uk/advanceanticipatory-care-planning-toolkit/dnacpr. aspx

Remember: DNACPR Forms only refer to cardiopulmonary resuscitation, not to any other treatments. Unexpected deterioration should always be assessed and managed appropriately irrespective of DNACPR status 31

Any Questions ? 32