Do Not Attempt Cardiopulmonary Resuscitation Policy (DNA CPR)
Patient Care and Professions
13th October 2010
Contents Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Appendices 1 2 3 4 5 6
Introduction Associated Policies, Procedures and Guidance Aims and Objectives Scope of the policy/procedure Accountabilities & Responsibilities Responsibility for making DNA CPR decisions Principles Underlying this Policy Patient Indecision Change of Status Mental Capacity
The Process of Making a DNA CPR decision Reviewing a DNA CPR Decision Record Keeping Emergency Situations Requests for CPR in a situation where it will not be successful The role of the family and relevant others Equality Impact Assessment Training Requirements Monitoring Compliance with this policy/procedure References Bibliography Key Stakeholders consulted/involved in the development of the document Guidelines on discussing DNA CPR decisions with patients and their families Framework for making DNA CPR decisions Do Not Attempt Cardiopulmonary Resuscitation form Equality Impact Assessment Tool Sign Off Sheet regarding Dissemination of Procedural Documents
Page 2 2 3 4 4 4 5 8 8 8 9 9 9 10 10 10 11 11 12 13 14 15 16 19 20 22 25
Policy Statement NHS Kirklees is committed to commissioning high quality services for patients, including end of life care. This embraces engaging with patients and clients as partners in care and respecting their wishes and preferences in all matters including the sensitive issue of cardio pulmonary resuscitation.
The focus of this policy is to provide guidance for cardio-pulmonary resuscitation (CPR) in situations in which decisions are made in advance and form part of the patients care plan.
CPR could be attempted on any individual in whom cardiac or respiratory function ceases. Such events are inevitable as part of dying and thus, theoretically, could be used on every individual prior to death. It is therefore essential to identify patients for whom CPR is inappropriate. It is also essential to identify those patients who would not want CPR to be attempted.
Some patients may wish to make an Advanced Decision to refuse treatment (ADRT) or a statement about treatment such as CPR. Those patients should be managed in accordance with their wishes ensuring the validity of the ADRT (MCA Code of Practice, Chapter 9)
This policy relates to the legal and ethical standards for planning patient care and decision making in relation to CPR, in accordance with the joint guidelines published by the British Medical Association, the Royal College of Nursing and the Resuscitation Council (UK) (2005). This policy takes account of the Human Rights Act of 1998, which came into force in October 2000.
This policy should be read in conjunction with the relevant professional standards and guidelines including the Nursing and Midwifery Council (NMC) publication The code of Standards of conduct, performance and ethics for nurses and midwifes (2008) and the General Medical Council (GMC) publication Good Medical Practice (2006).
Associated Policies, Procedures and Guidance
This policy should be read in accordance with the following PCT policies, procedures and guidance: • • • •
Basic Life Support Policy for Adults and Children Aged 16 and above Mental Capacity Act (MCA) policy and associated MCA Code of Practice Policy for the Protection of Vulnerable Adults Consent policy
Aims and Objectives
The purpose of this policy is to provide guidance to clinical staff and care home staff managing the care of patients in relation to DNA CPR decisions, ensuring they are fully supported in their role so that patients receive appropriate care. In particular the policy aims ensure compliance with the Care Quality Commissions standards around do not attempt resuscitation decisions and achieve a coordinated approach across the Kirklees area, so that the transfer of patients between services does not compromise dignity, quality of care or patient choice.
Specific objectives include: •
to avoid inappropriate CPR attempts
to ensure that decisions regarding CPR are made according to: o an assessment of whether CPR could succeed o the clinical needs of the patients o the patients wishes and best interests o current ethical principles o legislations as to the Human Rights Act (1998) and Mental Capacity Act (2005)
to make DNA CPR decisions transparent and open to examination
to clarify DNA CPR situations for clinical staff caring for people who have communication difficulties and other vulnerable groups
to ensure patients, relevant others* and staff have information on making decisions about DNA CPR and that they understand the process
to clarify that patients and relevant others will not be asked to decide about DNA CPR when clinicians are as sure as they can be that any CPR attempt would fail, and therefore is not a realistic or appropriate treatment option
to encourage and facilitate open, honest and appropriate discussion with patients and their relevant others about DNA CPR issues and give guidance on good practice in having these discussions
to ensure that a DNA CPR decision is communicated to all relevant healthcare professionals and services involved in the patients care.
*For the purpose of this policy, the term “relevant others” is used to describe patient’s spouses, partners, relatives, carers (who are not in a paid, professional capacity), representatives, advocates, donees and attorneys of a registered Health and Welfare Lasting Power of Attorney, independent mental capacity advocates (IMCAS), Court Appointed Deputies and guardians.
Scope of the policy/procedure
This policy must be followed by all NHS Kirklees employees who are developing policy and procedural documents or developing guidance for colleagues. It must be followed by all staff who work for NHS Kirklees (the PCT), including those on temporary or honorary contracts, bank staff and students. Breaches of this policy may lead to disciplinary action being taken against the individual.
Independent Contractors are responsible for the development and management of their own documents and for ensuring compliance with relevant legislation and best practice guidelines. However the Trust will endeavour to support them in abiding by the principles of this policy and support its implementation.
Staff working in independent healthcare facilities have a duty to comply with legislation and are encouraged to abide by the principles of this policy and support its implementation.
Accountabilities & Responsibilities
This policy has been developed in collaboration with key stakeholders and representatives from partner organisations (see Appendix 1).
Responsibility for making DNA CPR decisions
There is no ethical obligation to discuss resuscitation measures with patients for whom such a treatment, following assessment is judged to be futile, unless the patient raises the issue.
In the community, responsibility for making the DNA CPR decision lies with the patients General Practitioner (GP) or designated doctor in the case of patients in the care of a community hospital.
Cardiopulmonary resuscitation intervention should be considered by the multiprofessional team. Factors that should be explored by the team prior to discussing resuscitation as an option with the patient should include: • • • • • • • • • • •
Diagnosis Prognosis Quality of Life Responsiveness of Disease to Treatment Advance Decision to Refuse treatment (ADRT) Patients Wishes and any other statements they may have made about their treatment Moral Belief of the Patient (if known) Family Circumstances Age Spiritual Beliefs (if known) Likely Clinical Outcome of CPR and the Benefits if Successful
The Patients Human Rights, including the Right to Life and the Right to be Free from Degrading Treatment. (This is not intended to provide an exhaustive list)
The patients mental capacity should be assessed and clearly recorded. Once it has been decided to approach a patient (who has mental capacity) to ask if they would wish a resuscitation attempt to be made in the event of cardiopulmonary arrest, the following information should be made available to him/her as an aid to making an informed choice. • • • •
• • •
Ensure that the Patient understands what is meant by a cardiopulmonary arrest. Ensure that the Patient understands exactly what the cardiopulmonary resuscitation procedure involves. What the likelihood is of the patient having a cardiopulmonary arrest that will require such an intervention. The basic measures towards cardiopulmonary resuscitation that can be undertaken within the environment in which they are being cared for (e.g. home, place of respite care, during transportation etc). Need to call 999 for ambulance and transfer patient to hospital for advanced resuscitation measures if this is deemed necessary/appropriate. Chances of a successful outcome of treatment initiated in the patient’s home, other care environment or treatment initiated in the acute hospital environment. What will happen if the patient is unable or unwilling to make a decision about resuscitation for themselves The Patient should be reassured that they are entitled to review any decision they make at any time.
This information should ideally be given verbally by a senior member of the team involved in the patient’s care, who is in possession of all relevant clinical information.
If the patient lacks the mental capacity to make the decision, then the Statutory Principles of the MCA and it’s Code of Practice should be followed. The Best Interests statutory checklist and decision making process should be followed. Subsequent decisions should be recorded as being in the Best Interests of the person and a Best Interest Decision Maker should be appointed. There should be a clear audit trail of the process of decision making. Assumptions must not be made about someone’s Best Interests simply on the basis of the person’s age, appearance, condition or behaviour. The decision maker must not, in anyway, be motivated by a desire to bring about the person’s death (MCA Code of Practice).
Principles Underlying this Policy
Circumstance of cardio-pulmonary arrest If the circumstance of a cardiopulmonary arrest cannot be anticipated (i.e. it seems unlikely that circumstances would occur where the patient
would require CPR), it is not possible to make a DNA CPR decision that can have any validity in guiding the clinical team. In order to make an informed decision about the likely outcome of CPR, it is essential to be able to think through the likely circumstance(s) in which it might happen for the patient. It is unnecessary to ask patients or relevant others about CPR when it is deemed unlikely that circumstance would occur where the patient would require CPR. This should however never prevent discussions about CPR issues with the patient if they wish. 7.2
When CPR would fail In the situation where either •
death is expected as an inevitable result of an underlying disease and there is no prospect of treatment that might modify its course
a very sick patient is being actively treated with some hope of recovery, and the clinical team is as certain as they can be that CPR would fail, resuscitation should not be attempted
It is inappropriate to ask patients and relevant others to decide about CPR when it is not a treatment option that doctors (or other relevant senior clinician) feel would offer any benefit to the patient. Never the less discussion about CPR should be encouraged where deemed appropriate as part of helping the patient and their family understand the severity of the patients condition, unless it is clear that such a discussion would be unwelcome. Open and honest communication is essential in this situation. When a DNA CPR decision has been made because CPR is not a viable option, it is the responsibility of the medical/nursing team to ensure the patient and the family have the opportunity to be made aware of the severity of the patient’s condition (see guidelines on discussing DNA CPR decisions with patients and their families, Appendix 2) 7.3
Communication Throughout their care, the patient should be given as much information as they wish about their situation, including information about CPR. Relevant others can be given information if the patient agrees. It is not the clinicians responsibility to decide how much information the patient should receive. Their task is to find out how much the patient wishes to know or can understand. If a patient does not have capacity to make this decision, then the clinical team must decide the best option taking into account the knowledge of relevant others about the patients previous wishes. The MCA Best interest statutory checklist should be used. Relatives should not be placed in a position where they feel that they are making a DNA CPR decision unless they are the legally appointed. Their role is simply to provide information about the patients previously expressed wishes or what they believe the patient would wish in this situation.
However, a relative (or other person) may be the donee/attorney for the patient with a Health and Welfare Lasting Power of Attorney registered with the Office of the Public Guardian (MCA Code of Practice, Chapter 7). However a donee/attorney has no power to consent to or refuse lifesustaining treatment, unless the LPA document expressly authorises this. Staff should check whether there is a valid Advance Decision to Refuse Treatment (ADRT) (MCA Code of Practice, Chapter 9) and follow the person’s wishes. If there is a Court Appointed Deputy, they must be consulted. If the person has been assessed as not having the capacity to make the decision and has no relatives or friends able to assist him/her with the decision then a referral must be made to the Independent Mental Capacity Advocacy (IMCA) service. The IMCA does not make the decision, but gathers all relevant information and provides a report for the appointed Decision Maker, who is acting in the patients Best Interests. Communication needs and preferences must be determined in discussion with the patient and their family members/relevant others and every effort must be made to present and receive information accurately and in a way that everyone can understand. Where english is not the person’s first language, or they have a significant hearing impairment, they must be offered an interpreter (please refer to the Trust’s policy). A referral to the Speech and Language Therapy team to assist with ensuring adequate communication should be considered. When caring for children or young people, consideration needs to be given to their involvement in all aspects of palliative care. The issue of DNA CPR is particularly sensitive in this context and clinicians involved need to consider the issue of Gillick competencies in terms of discussion with the parent/s or guardian. As the Mental Capacity Act applies to people over 16, then consider the principles involved in this Act (or other law relevant to children) if there is a question of lack of mental capacity to make decisions. 7.4
Quality of life decisions based on benefits and burdens Medical decision should be based upon immediate health needs, and not a professional’s opinion on quality of life. Opinions on quality of life can be highly subjective. Where CPR may be medically successful, but result in what may be considered to be a poor quality or length of life, the patient’s wishes about wanting or not wanting CPR to be attempted are of paramount importance. Patients should be informed in a sensitive manner of the facts and of the possible risks and adverse effects in order for them to be able to make informed decisions.
Presumption to resuscitate When no explicit decision has been made about CPR before cardio pulmonary arrest, and the express wishes of the patient are unknown, it should be presumed that staff would attempt to resuscitate the patient.
Although this should be the general assumption, it is unlikely to be considered reasonable to attempt to resuscitate a patient who is clearly in the terminal phase of an illness. It is of great importance that teams caring for patients address CPR decisions so that other team members are not placed in difficult circumstances. It is suggested that any situation when a DNA CPR order should have been in place but wasn’t, should be reported using the organisations incident reporting systems. 8.
The patient may be unable or choose not to make a decision for themselves with regard to resuscitation measures, (staff should be aware that this may be because the patient could feel hurried into making a choice). If it is thought it would be helpful and with the patient’s permission, the patient’s family can be involved in helping the patient to decide, although the family is not allowed to make the decision on the patient’s behalf. If the patient is unable to make a decision, the patient’s General Practitioner may make the decision in the patient’s best interests, which they need to document as a best interest decision
Change of Status
If a patient is for cardiopulmonary resuscitation and there is a significant change in his/her condition, it may be necessary to review their resuscitation status. Any discussion about such changes will be led and directed by the patient’s General Practitioner, but will involve other team members.
Adults should be presumed to have capacity to make their own decisions unless there is evidence (gathered by an assessment) to the contrary. Patients are considered unable to make a specific decision for themselves if, at that time, they are unable to: •
understand the information relevant to the decision
retain that information in their mind
use or weigh up that information as part of the process of making the decision
communicate the decision (whether by talking, using sign language, visual aids or by other means)
Where there is reason to doubt capacity, it is important to establish whether patients do or do not have mental capacity to make their own decisions relating to the specific CPR decision.
An assessment of capacity must relate to the specific decision the patient is being asked to make and their ability to comprehend their situation and the implications of their decision according to the principles of the Mental Capacity Act (2005) and it’s Code of Practice.
Full guidance on establishing whether a patient has mental capacity can be found in the Mental Capacity Act (2005) Code of Practice and the NHS Kirklees policy and procedure for Implementation of the Mental Capacity Act (2005).
The Process of Making a DNA CPR decision
This process is summarised in a flow chart in Appendix 3.
Where patients are admitted to an inpatient setting, transferred between settings or admitted to a community caseload or Care Home, their CPR status should be considered as soon as is reasonable. When no explicit decision has been made about CPR, before a cardio pulmonary arrest, and the express wishes of the patient are unknown, it should be presumed that staff would attempt to resuscitate the patient. Although this should be the general assumption, it is unlikely to be considered reasonable to attempt to resuscitate a patient who is clearly in the end stage of a terminal illness.
Reviewing a DNA CPR Decision
Whenever a DNR CPR decision is made, a review date of no more than 6 months must be set by the clinician involved, or whenever there are significant changes in the patient’s condition.
All DNA CPR decisions must be documented, both in the patient’s clinical records and using the Do Not Attempt Cardiopulmonary Resuscitation form (Appendix 4). The circumstance surrounding the decision must be clearly stated, together with who was involved in the decision making process.
The DNA CPR form should be kept in the most appropriate place to facilitate access by staff involved in the patients care.
The following principles apply:
the person who makes a DNA CPR decision is ultimately responsible for ensuring that the decision is communicated effectively to other relevant health professionals in both primary and secondary care. The task of disseminating information about the decision to others providing care to the patient may be delegated to another member of the healthcare team, but it should be clear who has responsibility for ensuring that the task is undertaken
the senior nurse caring for the patient is responsible for ensuring that every DNA CPR decision is recorded in the nursing records, and that all those nursing the patient are aware of the decision
Whenever a patient is transferred between establishments or discharged home, it is imperative that any DNA CPR decisions are communicated between all who need to know. Including, ambulance crew, the receiving organisation/team and any staff temporarily involved in the patient’s care.
In the event of a sudden unexpected cardiopulmonary arrest associated with an anaphylactic reaction to the administration of medication or during the transfusion of blood products or induction anaesthesia, resuscitation should always be attempted (following Basic Life Support Policy & Procedure), unless this is contrary to the patients previously expressed wish.
It may be appropriate to temporarily suspend a DNA CPR decision during some procedures if the procedure itself could precipitate a cardiopulmonary arrest.
Requests for CPR in a situation where it will not be successful
The senior doctor responsible for the patients care has the authority to make a final decision, but it is wise to strive to reach a consensus with the patients, relevant others and staff. Should this be ‘with the patient, relevant others and staff’ or ‘with the patient’s relevant others and staff’
15.2 The Court of Protection may have to be approached for the final say. This is usually a last resort, although courts can be helpful in deciding complex cases. 15.3
Ideally this should be discussed with the patient or their relevant others if they lack capacity, as part of the consent process. Some patients may wish a DNA CPR decision to remain valid despite the increased risk of a cardiopulmonary arrest and the presence of potently reversible causes, others may wish the DNA CPR decision to be temporarily suspended, in any case their wishes must be respected.
The role of the family and relevant others
For a patient with mental capacity (i.e. capable of understanding their situation and the implications of what is being discussed), his or her agreement must be sought before discussing CPR issues with the relevant others. Where a patient with mental capacity refuses to allow such information to be disclosed to relevant others this refusal must be respected.
It is good practice to involve those closest to the patient in discussion about DNA CPR decisions, and patients should be encouraged to let staff know who they would like to be involved. Patients should also be asked who they would like to be involved in such decisions if and when they are no longer have mental capacity to do so themselves.
Relatives should never be given the impression that their wishes override those of the patient. They can give information about the patient’s wishes in order to inform a best interest decision, but should not be burdened with the decision. Where CPR might realistically be successful, the role of relevant other is to assist the patient in decision making or to state what they understand the patient’s wishes to be.
According to the Mental Capacity Act (2005) a formally appointed donee or attorney with a registered Lasting Power of Attorney (Health and Personal 10
Welfare) is able to make decisions for a patient who lacks capacity. It is important to note this is different from an enduring power of attorney (EPA) Existing EPAâ€™s must also be registered with the Office of the Public Guardian, but usually only cover property and affairs. However, any decision relating to life sustaining treatment by a deputee/attorney must be expressly authorised in the Lasting Power of Attorney(Code of Practice, Chapter 7). 16.5
If an adult lacks capacity and has no family or person(s) to advocate on their behalf, the Mental Capacity Act (2005) requires an Independent Mental Capacity Advocate (IMCA) to be consulted regarding all serious medical treatment decisions. In every case where there is genuine doubt about whether or not CPR would have a realistic chance of success, or if a DNA CPR decision is being considered on the balance of benefits and burdens, there is a statutory duty to refer to the IMCA service. An IMCA does not have the power to make a decision about CPR, but the IMCA will consult with relevant people and submit a report to the decision maker (usually the clinician in charge) who is making the Best Interests decision.
If a DNA CPR decision is needed when an IMCA is not available (for example at night or at a weekend), the best interest decision should be made and recorded in the health record. This decision should be discussed with an IMCA at the first opportunity.
Equality Impact Assessment
The NHS is committed to ensuring that healthcare services are equitable to all users and delivered in accordance with individual needs.
DNA CPR decisions will not be made on the grounds of age, disability, race, ethnicity or national origin, gender, religious belief, sexual orientation, domestic circumstances, social or employment status. This policy reflects this commitment.
This policy has been assessed in accordance with equality and diversity legislation, as set out in Appendix 5. On initial screening the policy has not identified an impact.
Discussions about DNA CPR are sensitive and complex and should be undertaken by experienced medical or nursing staff. It is recommended that staff have formal DNA CPR skills training in preparation for this clinical responsibility, observe senior colleagues as they undertake these conversations and reflect on their experience within clinical supervision and peer review.
Issues around DNA CPR are complex, training will link more broadly to the End of Life Training Strategy however due to the relationship with CPR suggested this will provide an appropriate forum to discuss and raise awareness about DNA CPR More detailed and specific discussion should be facilitated by line managers with relevant staff.
Monitoring Compliance with this policy/procedure
19 .1 Compliance with this policy will be measured through the audit of End of Life Care and the organisations incident reporting system. Serious incidents and key issues will be reported to the PCTâ€™s Assistant Director for Safety and Risk and will be brought to the attention of the Governance Committee via the Risk Management Overview Group. 19.2
Review of the policy will be undertaken by means of the organisations normal policy review process.
The British Medical Association, The Royal College of Nursing, The Resuscitation Council (UK). (2005) Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement.. Department of Constitutional Affairs, Code of Practice to the Mental Capacity Act ( 2007). HMSO. London. Nursing and Midwifery Council (NMC) (2008) Standards of conduct, performance and ethics for nurses and midwifes General Medical Council (2006) Good Medical Practice, London Human Rights Act (1998), HMSO, London Mental Capacity Act (2005), HMSO, London
BRITISH MEDICAL ASSOCIATION, (2000). The impact of the Human Rights Act 1998 on medical decision making. London, BMA Books. BRITISH MEDICAL ASSOCIATION (BMA), (2001). Withholding or withdrawing lifeprolonging medical treatment, 2nd ed. London, BMA Books. BMA, RCN, Resuscitation Council UK (2007) Decisions relating to cardiopulmonary resuscitation. BMA – the mental capacity act 2005 – guidance for professionals Feb 2007. COOPER, S et al (2006). A decade of in-hospital resuscitation: Outcomes and prediction of survival? Resuscitation, 68:231-237. GENERAL MEDICAL COUNCIL, (2001). Good medical practice; Ch. 3 and 6. London, General Medical Council. GILL, R., (2001). Decisions relating to cardiopulmonary resuscitation: commentary 1CPR and the cost of autonomy. Journal of Medical Ethics, 27:317-8 Human Rights Act (1998). London, HMSO. LUTTRELL, S., (2001). Decisions relating to cardiopulmonary resuscitation; commentary 2- some concerns. Journal of Medical Ethics, 27:319-20 Mental Capacity Act (2005) Mental Capacity Act (2005) MENCAP, (2001). Considerations of ‘quality of life’ in cases of medical decision making for individuals with severe learning disabilities. London, MENCAP. Pan-Lothian Do Not Attempt Resuscitation (DNAR) Policy. REGNARD C & RANDALL F (2005). A framework for making advance decisions on resuscitation. Clinical Medicine, 5(4):345-360 ROMANO-CRITCHLEY, G. SOMERVILLE, A. (2001) Professional guidelines on decisions relating to cardiopulmonary resuscitation: introduction. Journal of Medical Ethics, 27: 308-9. THORNS AR & ELLERSHAW JE (1999). A survey of nursing and medical staff views on the use of cardiopulmonary resuscitation in the hospice. Palliative Medicine, 13: 225-232. WATT, H. (2001). Decisions relating to cardiopulmonary resuscitation: commentary degrading lives? Journal of Medical Ethics, 27: 321-3.
Key Stakeholders consulted/involved in the development of the document
Stakeholders name and designation
Date feedback requested
Detail of feedback received
Kirklees Community Health Services
Suggested amendments provided
Clinical Governance Leads
Palliative Care Specialists
Mid Yorkshire Hospitals NHS Trust
Draft policy amended
Suggested amendments provided
Draft policy amended
Draft policy amended
Draft policy amended
Draft policy amended
Draft policy amended
Draft policy amended
Calderdale and Huddersfield NHS Foundation Trust
South West Yorkshire Partnership NHS Foundation Trust Project Officer, (Mental Capacity Act/DoLS)
Date feedback received
April 2010 February 2010
Suggested amendments provided Suggested amendments provided Suggested amendments provided Suggested amendments provided
September Noted 2010
Policy for ratification September by Governance 2010 Committee
Appendix 2 Guidelines on Discussing DNA CPR Orders with Patients and Families DNA CPR discussion with seriously ill patients should always take place in the context of the broader goals of care, using a step wise approach. The most appropriate senior clinician should conduct the discussion. Establishing the setting Check whether family members or relevant others should be present. Ensure comfort and privacy; sit next to the patient and consider introducing the subject by using a phrase such as: “I’d like to talk with you about possible health care decisions in the future” What does the patient understand? An informed decision about DNA CPR status is only possible if the patient has a clear understanding of their illness and prognosis. Ask an open question to elicit patient understanding about their current health situation. It is important to encourage the patient to talk; you may consider starting with phrases such as: “What do you understand about your current health situation?” or “What have you been told about your condition?” If the patient does not know/appreciate their current health status then this is time to review and consider the most appropriate way of doing this. What does the patient expect? Next, ask the patient to consider the future. Examples of ways to start this discussion are: “What do you expect in the future?” or “What are you hopes for the future, what is important to you? This step allows you to listen while the patient describes a real or imagined future. Most patients with advanced, life limiting 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. Listen carefully to the patient’s responses; most patients have thought a lot about dying, they only need the opportunity to talk about what they have been thinking. Setting up the conversation in this way permits the clinician or nurse to respond with clarifying and comforting comments such as: “So what you’re saying is, you want to be as comfortable as possible when the time comes” or
“What you’ve said is, you want us to do everything we can, but, when the time comes, you want to die peacefully”. When ever possible, ask patients to explain the values that underlie their decisions, i.e.: “Can you explain why you feel that way?” Discuss a DNA CPR order Use language that the patient will understand, try not to present a lot of information in one go. Don’t introduce CPR in mechanistic terms (i.e. “start the heart” or “putting on a breathing machine”). Never say “Do you want us to do everything?” “Everything” is euphemistic, and easily misinterpreted. Using the word “die” helps clarify that CPR is a treatment that tries to reverse death. To a layman, when the heart stops, the patient dies. If the patient and clinician mutually recognise that death is approaching, and the goals of care are comfort, then CPR is not an appropriate medical intervention and a clear recommendation against CPR should be made, you may say: “We have agreed that the most important thing for your care is to keep you comfortable. With this in mind, I do not recommend the use of artificial means of resuscitation to keep you alive. If you agree with this, 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?” If the clinical situation is more ambiguous in terms of prognosis and objectives of care, and you have no clear recommendation, the issue of DNA CPR can be raised by asking: “If your condition should seriously deteriorate, would you want us to make every possible effort to resuscitate you?” or “When the end approaches, what is the most important thing for us to do for you?” If you are asked to explain what is meant by artificial means of resuscitation, then describe the realistic purpose, risks and benefits of CPR in as much detail as appropriate for the patients needs. It may be preferable to start general and become specific later if necessary. Respond to emotions Strong emotions are common when discussing end of life issues. Typically the emotional response is brief. The most profound initial response to make may be silence, providing a reassuring touch. Establish a plan Clarify the orders and plans that will accomplish the overall objectives you have discussed, not just the DNA CPR order. A DNA CPR order does not address any aspect of care other than preventing the use of CPR, where this is deemed inappropriate or unwanted. It is unwise and poor practice to use DNA CPR status as a proxy for other life sustaining therapies. Consider using words like:
“We will do everything we can to meet your needs. However, if you die in spite of everything, we will not use CPR to attempt to resuscitate you” or “It sounds like we should move to a plan which the ultimate objective is to maximise your comfort. Persistent requests for CPR – understanding why? If you should find that despite explanations and discussion, the patient or family/surrogate continue to want CPR, and you think that it is unwise and not in the patient’s best interests. The seemingly unreasonable request for CPR typically could stem from several themes which it may be useful to consider: •
Inaccurate information about CPR
The general public has an inflated or unrealistic perception of CPR success. While most people believe that CPR works 60 – 85% of the time, in fact the actual survival to hospital discharge is more like 10 – 15 % and less than 5% for the elderly and those with serious illnesses. This is a time to review/clarify the indications, contraindications, potential outcomes and morbidity of CPR. Start the discussion by asking: “What do you know about CPR?” •
Hopes, fears and guilt
Be aware that guilt (I haven’t lived nearby to care for my dying mother) and fear (I’m afraid to make a decision that could lead to my wife’s death) are common motivating emotions for a persistent CPR request. Some patients or families need to be given an explicit recommendation or permission from the doctor, to stop all efforts to prolong life, to be told that death is coming and that they no longer have to continue ”fighting”. Whenever possible try to identify the underlying emotions and offer empathic comments that open the door to further conversation. Agreeing to a DNA CPR order for many patients is equivalent to their “choosing” to die. Acceptance of impending death occurs over a vastly different time course for different patients/families; for some it never comes. Some patients see CPR as a “last chance” for continued life. Probe with open questions, i.e.: “What do you expect to happen – What do you think would be done differently, after the resuscitation, that wasn’t done before?” Most patients usually describe hope for a new treatment. Use the opportunity to respond by describing that you are doing everything in your power to prolong and maximise the quality of their life. If the patient is not ready to discuss a DNA CPR order, don’t let it distract you from other important end of life care needs, emphasise the objectives you’re trying to achieve and save the discussion for a future time, good care, relationship building and time will resolve most problems. Finally it is important to remember your needs and the emotional/professional support you may require. Dealing with the challenges of end of life care is extremely demanding. Make good use of the professional support and advice available to you from your colleagues, palliative care specialist and pastoral support.
Appendix 3 Framework for making DNA CPR decisions Is cardiac or respiratory arrest a clear possibility in the patient’s current condition?
If there is no reason to believe that the patient is likely to have a cardiac or respiratory arrest it is not necessary to initiate discussion with the patient (or those close to patients who lack capacity) about CPR. If however, the patient wishes to discuss CPR, this should be respected.
Is there a realistic possibility that CPR could be successful?
When an advance clinical decision is made not to attempt CPR, it is not appropriate to ask the patients wishes about CPR, but careful consideration should be given as to whether to inform the patient of the DNA CPR decision. Where the patient lacks mental capacity and has a registered health and welfare Lasting Power of Attorney or Court Appointed Deputy or guardian, this person should be consulted about the decision as part of the ongoing discussion about the patients care.
1. Does the patient lack capacity and have a valid advance decision refusing CPR. 2. Does the patient lack capacity and have a registered Health and Welfare Lasting Power of Attorney?
If a second opinion is requested, this request should be respected wherever possible.
YES If a patient has made a valid Advance Decision refusing CPR, this must be respected. If an attorney, donee, Court Appointed Deputy or guardian has been appointed they should be consulted.
Are the potential risks and burdens of CPR considered to be greater than the likely benefits of CPR?
When there is only a very small chance of success, and there are questions about whether the burdens outweigh the benefits of attempting CPR, the involvement of the patient (or, if the patient lacks mental capacity, relevant others) in making the decision is crucial. When the patient is a child or young person, those with parental responsibility should be involved in the decision however, where appropriate, discussion with the young person should always be considered. When adult patients have mental capacity, their own view should guide decision making.
CPR should be attempted unless the patient has mental capacity and states that they would not want CPR attempted
Decisions about CPR are sensitive and complex and should be undertaken by senior members of the healthcare team and documented fully
Decisions should be reviewed and documented regularly within a time frame up to a maximum of 6 months or when circumstance change
19 Decision Making Framework taken from ‘Decisions relating to CPR, A Joint Statement from the BMA, RCN and Resuscitation Council (UK), Oct
DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION In the event of cardiac or respiratory arrest NO attempts at cardiopulmonary resuscitation (CPR) will be made. All other active treatment should be given. NHS No
Next of Kin / Emergency Contact
Date of Birth
Section 1 Reason for DNACPR: Select as appropriate from A - D (see reverse) A.
CPR would be unsuccessful because of the following medical conditions:
Discussion with the patient / relevant others is not compulsory in this situation but it is good practice to explain why CPR will not be attempted unless doing so would cause unnecessary distress. This has been discussed with the patient This has not been discussed with the patient because it would cause unnecessary distress This has been discussed with ……………….…………… (name) Relationship to patient:……….………… This has not been discussed with any relevant others Record details of discussions in the patient’s notes
The benefits of CPR would be uncertain, in terms of either length or quality of life.
This must have been discussed with the patient and/or relevant others. Record details in the patient’s notes.
C. CPR is against the wishes of the patient who has mental capacity to make the decision D.
CPR is against the wishes of the patient as recorded in a valid advance decision
Section 2 Healthcare professionals completing DNACPR form (see reverse) Name & Designation
Name & Designation (Counter Signature)
Section 3 Review of DNACPR decision (if appropriate) This order is to be reviewed by: Date: ………………………….. Review Date
Full Name and Designation
Next Review Date
AMBULANCE CREW INSTRUCTIONS In the event of a Cardiopulmonary Arrest, please do not attempt CPR or defibrillation for this patient. All other active treatment should be given. Any other specific instructions:……………………........................................................................................................ 20
These guidelines are based on an agreement within the Yorkshire and Humber SHA region. For more details refer to your local policy relating to DNACPR.
Section 1 Guidance (Please write legibly and with black ink) Option A 1. Record underlying condition/s eg poor Left Ventricular function, end stage obstructive airway disease, disseminated malignancy with poor performance status. 2. The term “relevant others” is used to describe a patient’s relatives, carers, representatives, advocates, people with lasting power of attorney, independent mental capacity advocates (IMCAs) and court appointed deputies (refer to Mental Capacity Act 2005) http://www.publicguardian.gov.uk and/or http://www.dh.gov.uk Option B This situation must be discussed with the patient / relevant others. Record details of your discussion in the patient’s notes. (NB: ‘relevant others’ is defined above Option A point 2). Option C Record details in the patient’s notes. For guidance on Mental Capacity Act, refer to MCA Code of Practice Option D The Mental Capacity Act  confirms that an advance decision refusing CPR will be valid and therefore legally binding on the healthcare team, if: 1. The decision is in writing, signed, witnessed and the patient is aged 18 or over; 2. It includes a statement that the advance decision is to apply even if the patient’s life is at risk; 3. The advance decision has not been withdrawn; 4. The patient has not, since the advance decision was made, appointed a welfare attorney to make decisions about CPR on their behalf; 5. The patient has not done anything clearly inconsistent with its terms; and 6. The circumstances that have arisen match those envisaged in the advance decision. 16 and 17-year-olds: Whilst 16 and 17-year-olds with capacity are treated as adults for the purposes of consent, parental responsibility will continue until they reach age 18. Legal advice should be sought in the event of disagreements on this issue between a young person of 16 or 17 and those holding parental responsibility
Section 2 Authorisation To find out who is authorised to sign here, including when a countersignature is required, refer to your local policy on decisions relating to cardiopulmonary resuscitation.
Review – In accordance with your local Policy.
It is considered good practice to review DNACPR status in the following circumstances: • At the consultant ward round, MDT or Gold Standards Framework meeting; • On transfer of medical responsibility (eg hospital to community or vice versa); or • Whenever there are significant changes in a patient’s condition. When the form is no longer valid, either because the patient is for CPR or because a new form has been completed, it must be marked as cancelled by making two thick, dark, diagonal lines across the form; writing CANCELLED in large capitals and adding your signature and date. It should then be filed in the patient’s notes.
COMMUNICATING DNACPR DECISIONS It is the responsibility of the healthcare professional completing the form to ensure that the DNACPR status is communicated to all who need to know. For patients being transferred between different care settings, it is essential that all professionals including Out of Hours (OoH) and Ambulance (eg Yorkshire Ambulance Service) are made aware of this DNACPR order 1. Send the original form with the patient 2. A photocopy should be retained in the patient’s notes (for audit) marked with the words ‘COPY’ in large capitals, signed and dated. 3. Ensure the patient/relevant others are informed. They may prefer the form to be placed in a clearly marked envelope. 4. For discharges to community settings: communicate and /or fax a copy to the GP, Out of Hours service, and as appropriate any other relevant services eg Hospice.
Appendix 5 Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Insert Name of Policy / Procedure
Language support staff/interpreters should be aware of the DNAR policy and process
Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race
Information on the choices should be made available in different languages (leaflets are not always suitable so other media should be investigated such as DVD, CD or radio). Issues & concerns raised by family/carers should be recorded and responded to
• Ethnic origins travellers)
NO • Gender
As above. The adverse impact on gender has not been quantified – data needs to be analysed on behaviour and choice in relation to resuscitation.
NO • Religion or belief
Religious belief, practice and needs should be recorded at the earliest opportunity. This should then be used as a basis for discussion when raising CPR and resuscitation choices & outcomes. Chaplains should be aware of resuscitation procedures so that they can explain and explore issues that the patient may raise.
Insert Name of Policy / Procedure Yes/No • Sexual orientation including lesbian, gay and bisexual people
Comments Patients, their family, carers and partners should feel able to disclose their sexual orientation if they wish to do so without concern of being treated less favourably. All incidents of homophobia should be taken seriously, recorded and challenged. The recommendations in the Equity Partnership Health Needs Assessment should be responded to with the development of an Action Plan in partnership with local LGB community organisations
The adverse impact on older people can be reduced by reviewing and analysing choices made by older people regarding resuscitation. All complaints should be investigated. Guidance and reports from organisations such as Help the Aged and Age Concern should be implemented. Support roles should be developed for older people in hospitals to ensure their needs and wishes are being expressed and met.
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
A local response to the recommendations from the independent inquiry (Sir Jonathan Michael 2008) should be developed across all health & social care agencies Involvement of local advocacy groups that work with all disabled people should be developed Staff training on learning disabilities should be developed & implemented with involvement of people who have learning disabilities
Insert Name of Policy / Procedure Yes/No 2.
Is there any evidence that some groups are affected differently?
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
Is the impact of the policy/guidance likely to be negative?
If so can the impact be avoided?
What alternatives are there to achieving the policy/guidance without the impact?
Can we reduce the impact by taking different action?
If you have identified a potential discriminatory impact of this procedural document, please refer it to [insert name of appropriate person], together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact [insert name of appropriate person and contact details].
Sign Off Sheet regarding Dissemination of Procedural Documents To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.
Title of Document:
Cardio-Pulmonary Resuscitation Policy for Terminally Ill Patients
13th October 2010
Placed on Website:
Published on Oct 27, 2010