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

DDo o NNot ot AAttempt ttempt CCardio-ardio-PPulmonary ulmonary

RResuscitation esuscitation (DNACPR)(DNACPR)

Dr Linda WilsonDr Linda WilsonConsultant in Palliative Consultant in Palliative Medicine Medicine Airedale/ManorlandsAiredale/Manorlands

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

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

This session:This session:

BackgroundBackground When/who to discuss with When/who to discuss with How to recordHow to record How to discuss- DVD How to discuss- DVD

Useful GuidanceUseful Guidance 2007: Joint 2007: Joint

guidance on guidance on DNACPR from UK DNACPR from UK Resus. Council, Resus. Council, BMA and RCN BMA and RCN

2007: Mental 2007: Mental Capacity Act 2005 Capacity Act 2005 (MCA) Code of (MCA) Code of Practice Practice

2010: Treatment and 2010: Treatment and care towards the end care towards the end of life: good practice of life: good practice in decision making. in decision making. GMCGMC

2010:NHS Bradford & 2010:NHS Bradford & Airedale Joint PolicyAiredale Joint Policy

Bottom lineBottom line

Resuscitation should be attempted in Resuscitation should be attempted in every patient who wishes for this to every patient who wishes for this to happen and for whom it has a reasonable happen and for whom it has a reasonable chance of successchance of success

Cardiac arrest is the final event in all Cardiac arrest is the final event in all deaths, inappropriate CPR may subject deaths, inappropriate CPR may subject people to an undignified death people to an undignified death

It is crucial to identify those patients with It is crucial to identify those patients with capacity who state clearly that they do not capacity who state clearly that they do not want CPR to be attemptedwant CPR to be attempted

Does CPR work?Does CPR work? Many hospital studies but not Many hospital studies but not

standardised standardised Overall around 10-20% survive to leave Overall around 10-20% survive to leave

hospital hospital Pneumonia, hypotension, renal failure, Pneumonia, hypotension, renal failure,

cancer, AIDS, sepsis, dementia, creatinine cancer, AIDS, sepsis, dementia, creatinine > 130 μmol/L, CVA, CCF all been > 130 μmol/L, CVA, CCF all been associated with a decreased likelihood of associated with a decreased likelihood of survivalsurvival

Public estimates of survival in the region of 50%

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 Summary

When to consider a DNACPR When to consider a DNACPR decisiondecision 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

DNACPR decision making- DNACPR decision making- 4 scenarios 4 scenarios

1.1. FutileFutile1.1. CapacityCapacity

2.2. Lack CapacityLack Capacity

2.2. May work May work 1.1. CapacityCapacity2.2. Lack CapacityLack Capacity

you are NOT OBLIGED to discuss it with you are NOT OBLIGED to discuss it with patients or their families, HOWEVER…….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

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.

If you think CPR may be If you think CPR may be successful…successful…

If patient has If patient has capacitycapacity You should offer

opportunities to discuss whether CPR should be attempted

Patient who lack capacity Patient who lack capacity and for whom CPR may and for whom CPR may

workwork 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 Make a best interests decision in

conjunction with family 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 IMCA if suitable family/others or legally appointed proxy to consult legally appointed proxy to consult

How to recordHow to record

The new form !The new form !

Process of transfer from one Process of transfer from one setting to another:setting to another:

Review DNACPR decision prior to Review DNACPR decision prior to transfertransfer

Original form to be sent with patientOriginal form to be sent with patient

Inform all relevant professionals Inform all relevant professionals (template) and handover forms(template) and handover forms

Discussing CPR 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.

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.

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.

SummariseSummarise 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

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?

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?"

Managing Persistent Requests for CPR

Consider obtaining a second opinion Don’t complete the form and return

to the discussion another time

DVDDVD

Questions / DiscussionQuestions / Discussion