national agenda Dr Juliet tspiller Consultant in Palliative Medicine Marie Curie Hospice Edinburgh

Transcription

1 The updated DNACPR national agenda Dr Juliet tspiller Consultant in Palliative Medicine Marie Curie Hospice Edinburgh

2 DNACPR an advance decision where CPR won t work or wouldn t be wanted

3 DNACPR not a palliative care specific issue but isrelevant for every patient withidentified identified palliative care need in every care setting Remember 1 in 3 patients in the acute. Prevalence study in patients in 25 Scottish hospitals (n=10,743) 10% died during their current admission 29% died within 12 months Clark et al ( 2014) Imminence of Death Among Hospital In Patients Pall Med 28(6)474 9

4 NHS Scotland DNACPR policy Launched 2010 and updated 2016 Emphasising existing best practice in CPR decision making UK guidance from; General Medical Council, British Medical Council / Royal College of Nursing & Resuscitation Council (UK) Providing framework for improved communication of DNACPR decisions across all care settings

5 Revised UK good practice guidance (June 2016) Emphasis on ACP Emphasis on communication Emphasis on clinically appropriate review Post Tracey judgement guidance Post Winspear Post Winspear judgement guidance

6 NEW 1. Patients must be made aware of a DNACPR decision when CPR won t work If that conversation cannot take place document; the clinical DNACPR decision without delay, the plan to review an opportunity to have the conversation, the reasons why the conversation can t take place. The only acceptable reasons for not having that conversation are High risk of causing psychological or physical harm The Patient has capacity but refuses to discuss it The Patient does not have capacity and reasonable efforts to contact PoA or NoK have failed

7 NEW 2. Those close to a patient who lacks capacity must be made aware of a DNACPR decision without delay when CPR won t work If that conversation cannot take place document; the clinical DNACPR decision without delay, the plan to review an opportunity to have the conversation, the reasons why the conversation can t take place. The only acceptable reasons for not having that t conversation are Judged to be not practicable Judged to be inappropriate

8 NEW 3. Where it is clinically certain that a DNACPR decision will be appropriate until a patient s death it does not need to be reviewed. e ed Review of decision Review not needed as decision will remain clinically appropriate until end of life Review needed on clinically appropriate basis Senior clinicians taking over clinical responsibility for the patient (transferring teams, discharge etc) must still review the decision and document that they are in agreement.

9 HIS DNACPR Indicators 1 % ofcorrectly completed DNACPR forms 2a % ofcase note entries compliant with case law relating to DNACPR documentation of patient and family involvement 2b Number of inappropriate CPR attempts where a DNACPR was in place 3a % of true cardiac arrests with post event DNACPR 3b % of CPR attempts stopped within 10 minutes 3c Total number of patients with no evidence of DNACPR decisions where death would not be unexpected due to advanced illness, significant frailty and/or co morbidity

10 The culture shift in communication DNACPR as a prompt not a focus? Puts death on the horizon for clinicians Prompts realistic planning decisions - what if they were to suddenly collapse - would CPR work - would ITU/HDU be appropriate - would they be for any resuscitative measures (fluids, blood, NIV etc) Prompts goals of care discussions - out of possible and realistic treatments what would the patient want?

11 The culture shift in communication DNACPR as a prompt not a focus? Puts death on the horizon for patients and their families Allows open and honest discussion i about; - understanding of their individual situation; - risk of sudden deterioration; ti - expectations and goals of care - treatment t t options (what is possible and what is not possible); - incompatible aspirations eg I want CPR but I don t want hospital admission.

12 Coming soon?.... Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) UK wide project wide stakeholder engagement Advance decisions about emergency care To supersede & replace integrated t ddnacpr forms All care settings / All age groups Developed with patients, carers and healthcare professionals Developed from existing evidence based models

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14 ReSPECT for NHS Scotland Gradually evolving picture Importance of engagement with existing local ACP models dl and DNACPR policy meantime Part of National ACP approach between HIS and Scot Gov (Person Centred Care workstream Living Well in Communities) Part of the NSS ehealth ACP development agenda KIS optimisation i i and future ehealth lh requirements for ACP Scottish Pilot and test of change as first step

15 Education resources NES online resources Open access video (part of online hospital doctors module) Online module for Foundation Year Doctors on TURAS Training powerpoints p available via SG and HIS websites GMS resources uk.org/guidance/28738.asp Communication skill training

16 Raising public awareness there s lots out there That ain t the way to die ZDoggMD /1B3 The Lady and the Reaper Thank you letter to David Bowie

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