Posted by: ayrshirehealth | January 28, 2015

Do Not Attempt Cardiopulmonary Resuscitation by @michaelcn67

Frozen with fear

My career long interest in cardiopulmonary resuscitation (CPR) stems from an unexpected baptism of fire to the potential realities of nursing as a very junior student nurse. EmergencyAs I walked into the ward for my first shift in my surgical placement, without any warning, a patient collapsed at my feet in cardiac arrest.   Rooted to the spot, frozen with fear, I was of no help to the patient whatsoever.

Thankfully, some nurses heard my exclamation of horror and quickly set about initiating CPR, whilst I stood embarrassed, vowing to myself that I would learn what to do should it ever happen again!

This was the event that shaped my career, sparked my interest in resuscitation and steered my ambitions to work in an area where I would be able to develop and utilise resuscitation skills.  Shortly after qualifying as a registered nurse, I was appointed to a Staff Nurse post in a Coronary Care Unit. Following some additional training, I was eventually deployed as a member of the cardiac arrest team to support the provision of Advanced Life Support skills for patients who had suffered a cardiac arrest. It quickly became clear to me that CPR is more successful in certain situations than in others. It also became apparent that death associated with unsuccessful resuscitation, was mostly invasive, undignified, brutal and traumatic.

Cardiopulmonary resuscitation

CPR is a treatment which was first developed in the late 1950s and has progressed significantly since Peter Safar and James Elam invented mouth-to-mouth resuscitation in 1956.  It is an emergency treatment designed to restart the heart and breathing when they have stopped. Mouth to mouthIt may include chest compressions, use of a mask or a tube to assist breathing, administration of medications and electric shock treatment to try to restart the heart. CPR could therefore be used in every case prior to death.

It can prevent premature death but it can also prolong inevitable suffering and lead to an unnatural delay in the dying process.   Consequently, it is essential that senior healthcare professionals identify those patients for whom CPR is likely to fail and/or is inappropriate.

It is also essential to identify those patients who have made an informed decision that they do not wish to be resuscitated.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) – The key issues

The NHS Scotland Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy (2010) was developed in an attempt to prevent inappropriate, futile and/or unwanted attempts at CPR. The current term “Do Not Attempt Cardiopulmonary Resuscitation” (DNACPR) was developed to help patients, families and healthcare professionals understand that we would withhold only chest compressions and artificial respirations in the event of a cardiac arrest. DNACPR does not mean do not treat. DNACPR Aide MemoirePatients, families and healthcare professionals should understand that other treatment options e.g. pain relief, IV fluids, sedation, blood transfusion, antibiotics, etc, will be provided where appropriate.

Our department has developed an aide-memoire to highlight the key priorities involved in making DNACPR decisions. These are described more fully in the following section.

Decision

Decision FrameworkThere are some important principles to be considered when a DNACPR decision is made. Every decision should be based on the individual patient circumstances. Blanket policies based on a clinical area, age or condition is never justifiable and may be illegal.

A framework for resuscitation decisions (picture 2) has been developed and can be used to assist decision making, if either of the following is relevant:

  • A patient makes a competent advance refusal
  • The treatment of CPR would not be of overall benefit for the patient

Need to Know

When a DNACPR decision has been implemented, we must ask ourselves ‘who needs to know?’ Patients, families and other healthcare professionals involved in the care need to be aware of the decision and understand the implications. Crucially, a recent English Appeals Court Ruling has resulted in new legislation which makes it unlawful to make and document a DNACPR decision without involving the competent patient.   The only acceptable justification for excluding the patient from the decision is that the conversation would cause “physical or psychological harm”. Timing of these discussions is crucial to ensure that the risk of any such harm is minimised. Furthermore, the rationale for excluding the patient/family from the decision/discussion must be clearly documented, in addition to a documented plan to enable future discussions at a more suitable time. The anticipated review of the national DNACPR policy will ensure that this new legislation is incorporated fully.

Accountability

The senior clinician (doctor or nurse), who is clinically responsible for the patient during an episode of care, has professional responsibility for making advanced decisions about CPR. In hospital, this will usually be the medical consultant. In palliative care, the community or community based hospitals, it could be the General Practitioner or an, experienced nurse/specialist.  The senior clinician is then responsible for all aspects of any DNACPR decision.   Specific guidance is provided in the event that a decision has to be made in the absence of the most senior clinician.

The NHS Scotland policy and recent guidance from the BMA, RCN and Resuscitation Council (UK) emphasises the importance of effective communication and agreement with the whole healthcare team.

Communication

DNACPR FormA single, highly visible, widely recognisable DNACPR from has been developed to standardise communication of such decisions across all care settings throughout Scotland (picture 3).   The Policy clearly outlines the importance of correct completion of the form, supported by effective documentation of the discussion and decision in the patient’s notes.

The recent Appeals Court judgement has further emphasised the importance of patient\family involvement in DNACPR decisions and robust unambiguous documentation of such discussions including details of who was present, when they took place, a summary of what was said and their understanding of what the decision means.

It is also crucially important that robust communication of DNACPR decisions occurs at any transfer or discharge interface, to ensure that everyone is aware of the decision.

Person-centred

Person-centred healthcare sees patients as equal partners in planning, developing and assessing care to make sure it is most appropriate to their needs.   It involves putting patients and their families at the heart of all decisions. (The Health Foundation: http://www.health.org.uk/areas-of-work/topics/person-centred-care/person-centred-care/). Building relationships with family members is also central to person-centred care.

It is vital that decisions relating to CPR take into account the patient’s needs and views. Taking account of confidentiality issues, family members should be informed of important decisions and plans for the care of their loved ones.

Review

The responsible clinician should determine the frequency of review for any DNACPR decision. The review timeframe will be determined by each individual case but should happen whenever changes occur in the patient’s condition or when clinical responsibility for the patient changes. When a DNACPR decision is made, an appropriate review date should be identified and recorded on the DNACPR form. New guidance highlights that there will be some patients for whom a DNACPR decision will be appropriate until their death and therefore there may be no need for further review.

Summary

The complex ethical issue of DNACPR decisions is relevant to the vast majority of healthcare professionals working in the acute and community settings. The NHS Scotland integrated adult DNACPR policy aims to prevent inappropriate, futile and/or unwanted attempts at CPR. They are intended as a positive step to help a person’s wishes to be followed at the end of life, irrespective of whether they are being cared for in hospital, hospice, care home or in their own homes. The NHS Scotland DNACPR policy is currently subject to a “light touch” review which is scheduled to be concluded by April 2015.

This week’s blog was by @michaelcn67 (Michael Canavan) – Michael works in NHS Ayrshire and Arran as Lead Resuscitation Officer and is responsible for the delivery of the resuscitation training programme across the organisation. The training programme is primarily focussed on promoting the skills which are most likely to result in positive outcomes from cardiac arrest. However, Michael is also keen to increase awareness that the realities of CPR are far removed from the common misconceptions that healthcare staff and the public alike hold.   Sadly, for many patients, CPR exposes them unnecessarily to a procedure that is traumatic and unlikely to have a successful outcome and may serve only to prolong suffering at the end of life. A significant proportion of the resuscitation training programme is therefore dedicated to heightening awareness of this complex area of care.

References

  1. R (On behalf of David Tracey personally and on behalf of the Estate of Janet Tracey (Deceased)) v (1) Cambridge University Hospitals NHS Foundation Trust (2) Secretary of State for Health [2014] EWCA Civ 822:54.
  2. Scottish Executive Health Department. Resuscitation policy (HDL (2000) 22). Edinburgh: Scottish Executive; 2000. NHS Scotland. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy. Edinburgh: Scottish Government; 2010. Available from: www.scotland.gov.uk/Resource/Doc/312784/0098903.pdf
  3. Decisions relating to cardiopulmonary resuscitation. 3rd Edition. Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. Resuscitation Council (UK); 2014. Available from: https://www.resus.org.uk/pages/dnacpr.htm
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Responses

  1. Thank you for sharing your knowledge and expertise in an area of clinical practice that is not familiar to me. I found the article both interesting and informative. If you could make one change to improve CPR care, what would it be?

    • Yes Michael. What one change would you make to improve care when you make a decision that CPR would not work …

  2. Micheal excellent reading can you post me a copy of decision pathway for Station 16 please. Also personally I think communication is the key to successful care at any level.

    • What one change would I make to improve CPR care? In order to provide an answer, I would like to be clear in my mind about what you are asking. Are you asking what one change could we make to improve care when we make a decision that CPR would not work?

    • I will do Morag. However, you will also find a copy of the decision making algorithm on the front of your ward copy of the DNACPR pad.

      • Cheers I did think I had seen it but then decided I had imagined it!

  3. I am not a clinician however my family had to make a difficult decision recently on this very issue and it would have been beneficial to have read this information beforehand. It is an excellent document and easy to read and understand.

    • Thanks for your comment Ann. I’m sorry you have gone through this difficult situation. The reason for writing the blog was to try to improve understanding of these difficult decisions and discussions. Best wishes.

  4. Great blog Michael…something I know very little about so found it really interesting and informative. I wondered though if rigid forms can lead to inflexible thinking by staff? How do we better support staff to have the confidence, time and space to effectively communicate with patients and their families about resuscitation?

    • Funny you should ask that Angela. That’s the focus of my ScIL Improvement project. First PDSA test next week hopefully.

  5. Thanks for writing this Michael , it is a clear, concise, measured explanation of the issues around DNACPR . Very informative and easy to read.

    I had a similar experience early in my nursing training and can relate to your shock and your response to learning so you didn`t feel like that again.

    • Thanks Marie. That’s what I was aiming for so I’m glad you found it informative.

  6. […] Do Not Attempt Cardiopulmonary Resuscitation by Michael Canavan on the AyrshireHealth blog. […]


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