DNACPR: review of current practice

Transcription

1 DNACPR: review of current practice Dr. Zoë Fritz On behalf of the DNACPR research group at Warwick University (Prof. Gavin Perkins - PI, Prof. Frances Griffiths, Dr. Anne-Marie Slowther, Prof. Robert George, Dr. Zoë Fritz, Mr. Philip Satherley, Mr. Barry Williams, Prof.Norman Waugh, Prof. Matthew Cooke, Mrs. Sue Chambers, Dr. Carol Mockford, Ms. Karoline Freeman, Dr. Amy Grove, Dr. Richard Field, Dr. Sarah Owens)

2 Why?

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6 and finally. Problems reported by clinicians Research Current practice being challenged by new approaches

7 One year Multi-Disciplinary project To identify current practice including Problems Exemplars of best practice

8 Specific questions What is the nature and frequency of issues related to DNACPR decision-making and implementation? What are the consistencies and variation in implementation of national guidelines? What are service provider perspectives on DNACPR decision-making in the NHS? What is the existing research for the processes, barriers and facilitators relating to DNACPR decisions

9 Information from different angles User views clinician/patient/relative Actual use in different health care settings

10 Methods Several projects in parallel: Review of complaints Review of use of patient help line Review of policies from 48 different trusts Focus groups Systematic reviews

11 Review of Complaints National Reporting and Learning System NHS Litigation Authority A Sample of trusts Parliamentary and Health Service Ombudsman Chief Coroner s Office Compassion in Dying (End of Life Rights Information Line)

12 Complaints - The size of the problem Overall proportion of incidents and complaints small (<0.5% of total number) National reporting and Learning system: 4538 incidents More than a third caused harm (141 deaths) Helpline received 110 calls between 1st Nov th June related to DNACPR NHS Ombudsman identified 33 complaints

13 Complaints - The Nature of the problem Considering Failure to anticipate need for DNACPR Clinical staff ignoring patient request for DNACPR Lack of information about DNACPR process Lack of public understanding DNACPR Discussing Sub-optimal or lack of patient / family involvement Discordant views (clinician, patient, relative) Implementing Poor documentation / record keeping Poor handover of decisions Failure to withhold CPR when DNACPR in place/requested Confusion over processes for form completion Confusion about frequency of review (Need for national policy 43) Consequences Harms to patients following CPR Fear of adverse consequences following CPR Death

14 Review of DNACPR policies 48 Trust policies 26 acute 12 communit Freedom of information requests to 48 English Health care trusts

15 Policy Review DNACPR policies assessed on their coverage of core ethical and legal issues approaches to communication how DNACPR decisions were implemented within and amongst healthcare settings.

16 Policy Review Considering Inconsistent terminology (DNAR, DNACPR, Not for CPR and AND) Variation in grade of decision-maker Lack of triggers Some patient info leaflets Discussing Limited guidance Mental incapacity gaps Implementing Expired policies Variation DNACPR forms (just under 1/3 used RCUK variation) Portability across different care settings Consequences

17 Examples of good practice

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19 Focus Groups 223 clinicians in 30 focus groups Pre-preprepared vignettes based on NCPOD cases Recorded, transcribed, analysed inductively ethical analysis also undertaken

20 Focus groups - thematic Considering Uncertainties (patient expectation/ quality of life/ desires) make DNACPR decisions difficult Best time for decision unclear (Community/ Acute setting) Discussing Many participants said DNACPR decisions should not be considered separately but as part of overall package of care Implementing Concern about variation in practice Consequences All focus groups mentioned witnessing a reduced quality of care for patients with DNACPR orders

21 Focus groups - ethical issues Resource implications Respect for patient autonomy is acknowledged in principle but proves difficult in practice - conflict with professional autonomy Recognising and responding to the interests of the family can be challenging for clinicians - societal expectations relevant Clinicians were concerned that a focus on DNACPR can have a negative impact on person centred care

22 rights and responsibilities equity duties of care Considering the decision Discussing the decision Consequences of the decision Implementing the decision MDT family person

23 Systematic Review Scoping review of literature exploring interventions that improved the process Review of Evidence of barriers and facilitators for DNACPR decision making Jan 2000-July references 47 included

24 Systematic Reviews Overall, the studies do not offer robust evidence Many lack detail of process, data collection etc. Resources and cost was seldom addressed BUT There are clear examples of good practice Problems had common themes despite cultural diversity

25 Systematic review - problems Considering Variability in decision-maker Variability in triggers & influencers Failure to anticipate, esp. where deterioration gradual Discussing Misunderstanding by clinicians of wishes Discussions hampered by: family aggression, Insufficient time levels, and combinations, of physician and nursing explanatory skills & patient understanding Implementing Significant variability in implementation of documentation Poor communication common Consequences Care & Rx may be suboptimal following a DNACPR decision

26 Systematic review - Improvements Considering The following has some evidence of helping: An MDT approach + patient/family Early and reviewable decision-making Using commonly understood language Contextualise resuscitation decision in goals of care Discussing Structure in the process benefits both the clinician & patient Education - multimodal approach for doctors helpful Implementing Consequences Standardised forms helpful Better as part of overall care planning:( e.g. UFTO) Clearer goals, Better communication. Earlier decision-making May be addressed by overall treatment plan

27 Examples of good practice only strong evidence in systematic review associated with reduction in harms

28 Consistent themes Considering Not anticipated early enough Disagreement about when the right time is - early? Huge variability about triggers for consideration Patients don t initiate Eduacation of patients/ society needed Discussing Implementing Discussions disliked by clinicians and patients Focussing on treatments to be given rather than withheld may help Problems with variability across and within health care settings standardised structured documentation may help Consequences May be addressed by overall treatment plan

29 Conclusions Problems all areas Need for consistent approach across health care settings -? Universal Documentation Need for education of public as well as clinical staff so that the consideration and discussion of DNACPR becomes easier Contextualise resuscitation decision within goals of care Several exemplars of good practice across the country - plan to try to combine best of each.

30 Thank you Funded by an NIHR HSDR grant - Team: Prof. Gavin Perkins - PI, Prof. Frances Griffiths, Dr. Anne-Marie Slowther, Prof. Robert George, Dr. Zoë Fritz, Mr. Philip Satherley, Mr. Barry Williams, Prof. Norman Waugh, Prof. Matthew Cooke, Mrs. Sue Chambers, Dr. Carol Mockford, Ms. Karoline Freeman, Dr. Amy Grove, Dr. Richard Field, Dr. Sarah Owens, University of Warwick. This review presents independent research funded by the National Institute for Health Research (NIHR) National Institute for Health Research (NIHR) Health Service Delivery Research Pro- gramme. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.