Do Not Attempt cardio-pulmonary Resuscitation (DNACPR) Policy CLP054

Transcription

1 Do Not Attempt cardio-pulmonary Resuscitation (DNACPR) Policy CLP054 1

2 Table of Contents Why we need this Policy... 3 What the Policy is trying to do... 4 Which stakeholders have been involved in the creation of this Policy... 4 Any required definitions/explanations... 4 Key duties... 5 Corporate Responsibility... 5 Director Responsibility... 6 Manager Responsibility... 6 Employee Responsibility... 7 Resuscitation Service Responsibility... 7 Policy detail... 7 Legal Issues... 8 Essential principles underlying decisions surrounding resuscitation... 8 Information to Patients Competent Refusal of Treatment Patient Refusal of a DNACPR Decision Patients Who Lack Capacity Children and young people Procedures for implementing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Orders Patient Transfers Confirmation or verification of death Care of the deceased Training requirements associated with this Policy Mandatory Training Specific Training not covered by Mandatory Training How this Policy will be monitored for compliance and effectiveness For further information Equality considerations Reference Guide Document control details APPENDIX 1 DNACPR Form AND DECISION FRAMEWORK

3 APPENDIX 2 PERSONAL RESUSCITATION PLANS APPENDIX 3 PERSONAL RESUSCITATION PLAN COMMUNICATION PROCEDURES APPENDIX 4 - COMMUNICATION FLOWCHART APPENDIX 5 - INFORMATION FOR PATIENTS AND CARERS Equality Analysis Report Why we need this Policy Cardiopulmonary resuscitation (CPR - attempting to restart the heart and breathing) can be attempted on any person in whom cardiac or respiratory functions have ceased. Failure of these functions is part of dying and thus CPR can theoretically be attempted on any individual as part of an attempt to preserve life. However, because there comes a time when death is inevitable for every person, it is essential to identify patients for whom cardiopulmonary arrest represents a final event in their illness and in whom attempted CPR may be inappropriate. It is also essential to identify those patients who do not want CPR to be initiated. It must be emphasised that every patient (and/or their family), for whom a DNACPR decision is considered, must be given the opportunity to be involved in the decision-making process, and be informed of the decision unless this would cause them harm, or they have stated that they do not wish to be involved or informed. This policy does not distinguish between basic and advanced resuscitation since the underlying ethical and legal principles about how decisions should be reached are the same. It is most important however, that it is understood that a decision not to commence CPR does not in any way diminish the importance of on-going medical and nursing care. The change of focus of care should be effected by those involved in managing the patient and should be assisted by the appropriate palliative care services. It must be emphasised that the implementation of a DNACPR decision relates solely to the withholding of artificial ventilation and delivery of chest compressions to a person in cardiac arrest. All other treatments and interventions deemed appropriate will be given. 3

4 The responsibility for making decisions about resuscitation lies with the Consultant or General Practitioner (GP) in charge of the patient s care. Where a valid Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision is not available in the Medical records (or appropriate location) and the precise wishes of the patient are unknown, cardiopulmonary resuscitation should be initiated if cardiac or respiratory arrest occurs. What the Policy is trying to do This policy has been developed to provide the Trust s employees and patients with information relating to decisions surrounding resuscitation. It also lays out the appropriate course of action to be taken when discussing, making, documenting and communicating such decisions. Which stakeholders have been involved in the creation of this Policy The Trust s Executive Team Trust Policy Board attendees Any required definitions/explanations ADRT (Advance Decision to Refuse Treatment) is a decision made by an individual whilst in possession of Mental Capacity and when valid, allows the refusal of any treatment in given circumstances. CAD (Court Appointed Deputy) the Court of Protection appoints a person to make decisions for someone who lacks capacity. CPR (Cardiopulmonary resuscitation) - refers to the act of attempting to restart the heart and breathing). 4

5 DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) refers to the actual act of not providing active resuscitation and does not in any way diminish the importance of on-going medical and nursing care. (Please note that the terms; DNAR (Do Not Attempt Resuscitation) and DNR Do Not Resuscitate; may also be found and have the same meaning.) IMCA (Independent Mental Capacity Advocate) support people who lack capacity and represent their views if there is no one else to fulfil this role. IV (Intravenous) LPA (Lasting Powers of Attorney) enables someone to give powers to a person to make decisions for them in the future if & when they lack capacity to look after their own personal and financial affairs. MCA (Mental Capacity Act) refers to the 2005 Act and its accompanying Code of Practice in relation to people who lack capacity to make particular decisions. NHFT (Northamptonshire Healthcare NHS Foundation Trust) PRP (Personal Resuscitation Plan) A plan laying down which interventions to make and which to omit in given circumstances relating to end of life care. It is predominantly used in paediatric care. SC (Subcutaneous). Key duties Corporate Responsibility Healthcare organisations have an obligation to offer appropriate care to their patients and appropriate training to their staff. 5

6 The Chief Executive, on behalf of the Trust Board, has overall responsibility to ensure the Trust complies with its statutory obligations. The Trust Board has overall responsibility for ensuring that all staff have received appropriate training to enable them to effectively fulfil their role within the organisation. The Trust Board has responsibility to ensure adequate provision of procedures to discuss, make, record and communicate decisions surrounding resuscitation. It is the Trust s responsibility to ensure that appropriate training is available. Director Responsibility Directors of clinical directorates, the Medical Director and Director of Nursing have responsibility for implementing and monitoring the effectiveness of this policy. Executive directors are responsible for ensuring staff within their service areas comply with this policy. They must ensure all staff are supported and released to attend training. Directors are responsible for ensuring action plans to address areas of noncompliance with this policy are fully implemented. They are responsible for dealing with areas that consistently non-comply with the requirements of this policy. The Medical Director is additionally responsible for ensuring that all doctors responsible for making and reviewing DNACPR decisions are adequately trained. This responsibility may be discharged by delivering or arranging appropriate training for staff and ensuring completion. Manager Responsibility Managers are those individuals who have line management responsibility for other members of staff within the organisation. Managers are responsible for ensuring that all their staff are aware of this policy, have read it, and have received appropriate training, through clinical supervision. They are also responsible for ensuring that relevant staff are aware of the DNACPR or PRP process and its implications to patient care. Managers should ensure that all staff are enabled to attend training appropriate for their role in accordance with the requirements of this Policy. Clinical Managers are expected to ensure that appropriate documentation is completed for all patients subject to DNACPR or PRP within their clinical area. They must also ensure that this policy and other appropriate information relating to decisions surrounding end of life care is available to patients and their carers. 6

7 Employee Responsibility All staff (permanent, temporary, locum and bank) directly employed by Northamptonshire Healthcare NHS Foundation Trust, sub-contracted or seconded to the organisation, must be aware of this policy and adhere to the procedures and practices herein. It is the responsibility of each staff member (as defined above) to maintain appropriate competence in issues surrounding DNACPR and PRP. Each staff member is responsible for reporting any shortcoming in their knowledge. Staff must ensure that the resuscitation status of a patient is discussed, where they feel it is necessary, that the appropriate discussions with the patient, their representative, their family, and multi-disciplinary team are had and that decisions are documented as per this policy. Staff also have a duty to follow the guidance in this policy where a decision regarding resuscitation status cannot be reached. All clinical staff have a responsibility to raise concerns relating to an individual s resuscitation status and ensure that this is discussed with the appropriate clinical team. Consultants and General Practitioners are required to make, endorse and document decisions relating to resuscitation according to this policy. Resuscitation Service Responsibility The Resuscitation Service is responsible for: delivering DNACPR familiarisation training during all BLS and ILS sessions developing and delivering specialist training packages (e.g. for doctors) relating to DNACPR on request advising the Trust on developments and changes in matters relating to DNACPR and resuscitation status internally advising in all matters relating to resuscitation status maintaining and updating their own knowledge and skills Policy detail This policy should be read in conjunction with the joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing (Decisions relating to Cardiopulmonary Resuscitation: October rd Edition), the current East Midlands Unified DNACPR Guidelines, East Midlands Children s and Young People s EOL Strategy (where appropriate), the NHS Constitution (2012), the Court judgements in Tracey (2014), the guidance promulgated from the Resuscitation Council (UK) following this decision and any subsequent relevant guidance or standards. 7

8 When dealing with patients who may lack capacity to make decisions relating to resuscitation, then this policy must be read and implemented in conjunction with CLP023 - Mental Capacity Act (2005) Policy. Legal Issues In order to meet their obligations under the Human Rights Act (1998), health professionals must be able to show that their decisions are compatible with the human rights set out in the Articles of the Convention. Provisions particularly relevant to decisions about attempted CPR include: The right to life (Article 2). To be free from inhumane or degrading treatment (Article 3). Respect for privacy and family life (Article 8). Freedom of expression, which includes the right to hold opinions and to receive information (Article 10). Freedom from discriminatory practises in respect of these rights (Article 14). The spirit of the Act, which promotes human dignity and transparent decision making, is reflected in this policy. If any concerns arise regarding the application of a DNACPR order, the senior doctor in charge of the patient s care should be informed. If concerns still exist, the Medical Director should be informed and the advice of the Trust s legal advisors should be sought. Essential principles underlying decisions surrounding resuscitation Who makes the decision? Except when a competent patient has refused treatment, the overall responsibility for decisions about and DNACPR orders rests with the consultant or GP in charge of the patient s care. S/he should always discuss the decision for an individual patient with the other health professionals involved in the patient s care. When to consider a DNACPR order. Cardiopulmonary arrests can be sudden and unpredictable. However, a decision concerning the appropriateness of undertaking CPR should be considered where cardiac arrest is foreseeable. Deterioration in the patient s health, an expressed opinion of the patient, their family, the wider healthcare team, or the terminal nature of their condition may prompt such consideration. Where care is shared between two or more clinical areas, the doctors involved should discuss the issue with each other. All patients subject to a DNACPR order in the East Midlands Ambulance Service region will transfer with that decision from one place of care to another, and that will remain valid, until reviewed. 8

9 How to make a decision. All patients must be assessed individually, and be fully involved in decisions relating to them, as is their right. Any decision about resuscitation must be made in the best interests of the patient. All such decisions should be made in discussion with the multi-disciplinary team, and must involve the patient, their relatives, friends or carers and others involved or with an interest in the patient s welfare including LPAs, CADs & IMCAs unless they have stated they do not wish (them) to be involved. Where necessary, appropriate interpretation services must be provided. Patients must be given adequate opportunities to discuss advance care planning including the appropriateness of resuscitation. If patients indicate they do not wish to discuss resuscitation, this should be respected. Where such discussions are likely to cause harm to the patient, relatives or carers, they may be omitted. Where a DNACPR decision is made and has not been discussed with the patient, this must be documented in the health and social care records and the reasons given. (See Treatment and care Towards the End of Life: Good Practice in Decision Making. GMC. (2010) s56 et seq. and Tracey (2014) Success in CPR is dependent on many factors. Patients and relatives often have an unrealistic expectation about the likely outcome of CPR. Where it is clear that CPR would provide no benefit to the patient, a medical decision to withhold CPR may be made. This should be based on the best available information. A DNACPR order should be made only after the appropriate consultation and consideration of all relevant aspects of the patient s condition. For example: Is a cardiac arrest a clear possibility? Is there a realistic chance that CPR could be successful? Are the risks and burdens of CPR likely to be greater than the benefits of CPR? The patient s human rights: CPR can be deemed inhumane and degrading treatment in cases of irreversible disease, where there is no realistic chance of success. In these circumstances DNACPR would be appropriate. If the patient is lacking capacity then the MCA decision making framework must be followed, including best interests assessment and involvement of IMCA, CAD and LPA where appropriate. Patient s known wishes Except in cases where it is the patient s sustained wish not to have CPR carried out, doctors should be cautious of making a DNACPR order where no clear pathology is present, as this would mean that a cardiac arrest is not foreseeable, and thus arrest would be unexpected. See also Appendix 1 - DNACPR Framework 9

10 What effect does a DNACPR decision have? The application of a DNACPR decision means that if a patient suffers a cardiac or respiratory arrest, the emergency services will not be called and neither basic nor advanced cardio-pulmonary resuscitation will be given (see sec for information Overriding an ADRT or DNACPR decision.) All other treatments, in the absence of a separate decision to withhold them, will be given up to the point of cardiac/respiratory arrest. (See sec relating to Other Treatment for further information) Information to Patients Information is available to all patients to explain the decision-making process. Patients and their carers should be encouraged to review such information as part of advance care planning. This information is intended to reassure patients of their part in decision-making. Relatives and patients must be offered time to discuss issues surrounding resuscitation with their doctors and nurses. Written information on end of life care planning and regional guidance is available from East Midlands Ambulance NHS Trust, and on their website National guidance is also available on the Resuscitation Council (UK) website Discussions relating to resuscitation are highly sensitive and complex and, where they are regarded appropriate, should be undertaken by senior members of the medical team, with advanced communication skills, supported by similarly experienced nursing colleagues. (See Treatment and care Towards the End of Life: Good Practice in Decision Making. GMC. (2010) s55) In some circumstances, especially in palliative care, careful consideration as to whether to disclose this decision to the patient should be made, as, whilst best practice is served by full involvement of the patient and family and communicating to them such decisions, the revelation or discussion may provoke great distress or anxiety. Practitioners must be aware that not to involve patients in this decision may also cause anxiety, and for this reason, unless it would be harmful to the patient, they must be offered the opportunity to participate. Careful and sensitive communication should be applied in broaching the subject. See Addx 5 for further information. Where it is decided not to discuss or reveal the decision, clear reasons and rationale must be documented in the medical notes. (See Treatment and care Towards the End of Life: Good Practice in Decision Making. GMC. (2010) s56 et seq.) Competent Refusal of Treatment At the time that a patient requires resuscitation, s/he will lack capacity. In rare circumstances they may verbally refuse resuscitation just before the collapse. In cases such as these CPR should be instigated in order to save life. Where a senior doctor has had time to assess capacity and decide against resuscitation, CPR need not be given. The MCA governs assessments and decisions relating to incapacitated 10

11 adults. Further guidance should be sought from the MCA Policy and MCA Code of Practice. (Also consider Treatment and care Towards the End of Life: Good Practice in Decision Making. GMC. (2010) s69 et seq.) Advance decision to refuse treatment (ADRT) If a patient has a valid and applicable advance decision to refuse treatment (ADRT) then this should be treated as a current refusal of consent to treatment and must be respected. It is not valid if the patient withdrew the advanced decision at any time when s/he had mental capacity, or has done anything clearly inconsistent with the advanced decision (for example has previously accepted the treatment the ADRT refuses). It is only valid if it is known that the patient had capacity at the time it was made. It must specify the treatment and the circumstances precisely. If there are reasonable grounds for believing that circumstances exist which the patient did not anticipate and which would have affected their decision then the advanced decision is not applicable. An advance decision to refuse life-sustaining treatment must meet the following specific requirements: must be written and dated must be signed (if the person is unable to sign they can direct someone to sign on their behalf) must be witnessed and dated must include an expressed statement that the decision stands even if my life is at risk as a result Best practice is served by having any ADRTs refusing resuscitation supported with a DNACPR to improve clarity. Any patient who is admitted to an inpatient area within the Trust with a valid and applicable ADRT specifying that they do not want resuscitation must have a DNACPR form completed as per Appendix 1 of this Policy. Patient Refusal of a DNACPR Decision Some patients may ask for CPR to be attempted, in spite of clinical judgement that it will not be effective or restore a good quality of life. Sensitive efforts should be made to convey a clear and realistic view of the procedure and its likely success. Whilst clinical staff may respect their wishes, it should be remembered that clinicians cannot be required to give treatment against their clinical judgement. Discussions between the patient and the team should be aimed at securing an understanding and acceptance of a decision. If the team is unable to reach a successful conclusion, a second opinion should be offered, and then legal advice sought. Under current case law, it is not legally required to seek a second opinion for a patient if the multi-disciplinary team are in agreement that a DNACPR order is appropriate and justified in the circumstances. 11

12 Patients Who Lack Capacity A person must be assumed to have the capacity to make a decision, unless it can be established that they lack capacity. All decisions made on behalf of a person who lacks capacity must be made in that person s best interests. In the absence of a valid ADRT, DNACPR order, decision from a CAD or LPA, the person s best interests will be served by performing CPR, in an emergency. If a decision relating to resuscitation is to be made, a decision-specific assessment of the person s capacity must be made specifically relating to the DNACPR decision. Please refer to sections 4 & 5 of CLP023 - Mental Capacity Act Policy and chapter 4 of the MCA Code of Practice for detailed information around assessing capacity. Assessments of Capacity should be clearly recorded on the Trust s Mental Capacity Assessment Form MC1. If the patient has a Lasting Power of Attorney in place, or a Court Appointed Deputy, authorised to make decisions in respect of CPR, then the decision of the LPA/CAD should be respected, however the LPA/CAD is still unable to demand a treatment/intervention. If the assessment shows that the person lacks capacity to make a decision relating to DNACPR, the decision must be made on their behalf using the best interest guidelines. These are set out in the MCA Code of Practice. In some cases not all of these factors will be relevant, and in others additional factors may need to be considered. Please refer to section 6 of CLP023 - Mental Capacity Act Policy and chapter 5 of the MCA Code of Practice for further guidance when determining best interest decisions. Best interest decisions should be clearly documented, including as much information as possible on the Trust s Best Interest Checklist Form MC2. Lasting Powers of Attorney (LPA) An LPA allows the patient to give authority to make decisions about a range of issues including personal welfare and health decisions to a nominated individual. For an LPA to be valid, it must be in a prescribed form, registered with the Office of Public Guardian and specify authority under the LPA to refuse life-sustaining treatment on behalf of the patient in the circumstances in which they are found. The LPA must act in the patient s best interests at all times. Independent Mental Capacity Advocates (IMCAs) NHS bodies must instruct an IMCA to represent and support a person who lacks capacity and has no family or friends to support them or consult when making a decision about serious medical treatment. The IMCA must be consulted prior to 12

13 the DNACPR decision being made. The IMCA is an advocate not a decision maker. Family and friends It is a statutory requirement that family and friends are consulted if a patient lacks capacity and clinicians wish to act in his or her best interests. Friends or relatives of patients often believe that they will be the decision maker for the patient, however no person is legally entitled to give consent to medical treatment on behalf of an adult who lacks decision-making capacity, except where there is a LPA in place. Clinicians have authority to act in the patient s best interests where consent is unavailable. People close to the patient should be kept informed and may be asked to reflect the patient s views and preferences, but it must be made clear to them that their role is not to make decisions on behalf of the patient. It is helpful for the clinician ascertain known prior wishes of the patient from family and friends whilst making a best interest decision Children and young people A child is someone under the age of 18. The MCA applies to anyone aged 16 and over but they cannot make an ADRT or give an LPA until the age of 18. As a general rule, the wishes of a child a Gillick competent child, who has sufficient understanding and intelligence to understand what is proposed by way of treatment, should be respected. Decisions relating to resuscitation should be made in full consultation between all relevant professionals and the parents. Staff should not rely solely on the wishes or directions of parents. Parents or anyone with parental responsibility must, however, be consulted as to whether the proposed contents of the Personal Resuscitation Plan (PRP) seem appropriate. Where feasible, the child s wishes should be obtained. (See for basic information on Gillick competence ) It will normally be the case that the overall responsibility for drafting and reviewing PRPs rests with the Consultant Paediatrician. S/he should draft and review the PRP in consultation with the relevant nursing teams. The PRP must be recorded in the documentation found at Appendix 2. If agreement cannot be reached as to whether CPR or other emergency treatment would be in the best interests of the child, e.g. there is an issue between staff and parents about the application of a PRP, a Court declaration should be sought. The consultant and nursing team must ensure the plan is communicated to all those involved in the child s care. It must be ensured that schools where children subject to a PRP attend, are fully aware of the PRP, are issued with copies and updates as necessary and that there is full and effective communication between all medical and nursing teams working with that particular child and school. See Appendices 2 & 3. 13

14 If a child is incompetent, in the absence of a PRP, staff should provide emergency treatment in child s best interests, using the same principles that apply to adults. In an emergency situation, any doubt should be resolved in favour of preserving life. Procedures for implementing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Orders Recording and communicating decisions Any decision relating to resuscitation must be communicated to the entire team of health professionals caring for that patient. A DNACPR decision should be reviewed on each transfer of care, but remains valid until it is reviewed as appropriate. The senior doctor is responsible for writing and authorising the order, then informing relevant clinical staff (e.g. nursing teams, other departments, and those areas required to be aware) that the order is in existence. If a DNACPR decision is made, the doctor in charge of the patient s care (i.e. Consultant or GP) is responsible for ensuring that the DNACPR form is completed (as per Appendix 1) and the printed, signed original form is retained in the front of the patient s notes. A copy should be scanned onto the electronic patient record, for audit purposes. Hierarchy of locations for filing DNACPR forms 1 st page multidisciplinary notes (single care record) (if used) 1 st page medical notes (if used) 1 st page nursing notes including community services notes (if used) With Physical Healthcare Records (ward areas) 1 st page in other healthcare notes Prominent location in the patient s home (e.g. LION S pot) It is imperative that the original form is printed, signed, and easy to find. As the priority is to try and preserve life, there is not time to search for an absent DNACPR / PRP form. The NCEPOD report Cardiac Arrest Procedures: Time to Intervene (2012) states that missing or misfiled DNACPR forms are a leading cause of distressing inappropriate resuscitation attempts. The decision and any surrounding conversations must also be documented within the contact section of the patient s notes/electronic records. If the patient is discharged or transferred to another healthcare establishment, whilst still subject to a DNACPR, the original DNACPR form MUST accompany the patient at all times. When completing a DNACPR order, it must be completed with the following information: Patient s details. 14

15 Date of decision. Assessment of patient s capacity. Clinical reasons for decision. Summary of communication regarding the decision with patient or their Attorney. Summary of communication with patient s relatives or friends. Names of multi-disciplinary team members contributing to the decision. Name, position and signature of healthcare professional completing the decision. Review and endorsement by doctor in charge of the patient s care (Consultant or GP). Review date if appropriate. *- in circumstances where a patient has a terminal condition, or has expressed a desire not to be resuscitated, it may be appropriate for the decision to not require review by a specified date. When completing a PRP, it must be completed with the following information: Child s details. Up to date photograph of the child. Date of decision. Specification of review date if necessary. Background and reasons for the plan. Names of family and multi-disciplinary team members contributing to the decision. Endorsement by child s consultant. Name and signature of parent or guardian, child, if appropriate, senior nurse and GP. Plan information as indicated on documentation. Other treatment Distinct from a PRP, a decision not to attempt resuscitation applies only to CPR. It must be made clear to the patient and members of the health care team that it does not imply non-treatment and that all other treatment and care that are appropriate for the patient will continue to be considered and offered. To avoid all confusion, the expression not for attempted cardiopulmonary resuscitation should be used. In adult settings, a separate document, commonly known as a Ceiling of Care (CoC) statement may also be made by the senior clinician. This will define which treatments will or will not be given. These may include the withholding of IV or SC fluid therapy, decisions not to treat infections, not to give supplemental oxygen etc. This will be documented clearly in the patient s notes. In the absence of such a decision, all other active care will be given to the patient up to the point of cardiac arrest. 15

16 The Personal Resuscitation Plan (PRP) also has facility to describe what level of treatment would be given in any particular circumstance. This should be fully completed in order to avoid any potential confusion. Overriding an ADRT, DNACPR decision or PRP In some circumstances it is appropriate and necessary to ignore or override a CoC plan, DNACPR order, PRP or an ADRT and give treatment and/or resuscitation. Such instances could include (not exclusively): Reversing a sudden palliative care emergency, such as acute hyperkalemia and treating anaphylaxis or choking. Resuscitation must be attempted following a deliberate self harm or suicide attempt. Procedures for reviewing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Orders Where clinically appropriate, DNACPR orders must be reviewed in light of changes to the patient's condition and wishes. The frequency of reviews are to be determined by the Consultant or GP in charge of the patient s care and will be influenced by the patient's diagnosis, potential for improvement and response to treatment. A decision may be changed as a result of either a change in health or a change in legal status of the patient. The review must be clearly documented. In circumstances including where a patient has a life-limiting condition, particularly in palliative care, the decision may be made that the DNACPR does not require review in this case, this should be clearly indicated in the review section of the form. Decisions about resuscitation status must also be reviewed if a clinician, the patient themselves, or a relative believes the patient s condition has changed. The consultant or GP should be contacted as soon as possible with a request to review the DNACPR status. Cancelling a DNACPR order To cancel a DNACPR order a diagonal line must be struck through the form. The doctor s signature, name, date and time and the reason must be clearly written. The form can then be removed and filed. Patient Transfers When transferring a patient, the original DNACPR form or PRP should remain filed in the accompanying medical notes or patient care record. Photocopied DNACPR forms or PRPs should not be sent unless they are acceptable to the transferring ambulance service and receiving healthcare provider Internal transfers and all accompanied visits off Trust premises If the patient is transferred to another ward or hospital, the DNACPR order or PRP will remain in place until reviewed by the new consultant. 16

17 If the patient is transferred to another consultant, the DNACPR order or PRP will remain in place until reviewed by the new consultant. If a patient is taken off Trust premises and is accompanied by a member of Trust staff, the original DNACPR order or PRP must travel with the patient and be adhered to if necessary. Transfers into NHFT Services Where a patient is transferred into an NHFT service with a current and applicable East Midlands unified, or other appropriate form of DNACPR, this decision will be upheld until it is reviewed by the receiving consultant. Transfers out of NHFT Services When a patient is transferred out of NHFT services with a DNACPR order, the original order must accompany them and should be reviewed by the GP or consultant taking charge of the patient Confirmation or verification of death Death should be confirmed by a registered medical practitioner or verified by a suitably trained registered nurse. Only doctors are permitted in law to certify death. Verification should only be carried out, by an appropriately trained registered nurse, in cases of expected or predictable death, according to the Nurse Verification of Death Protocol CLPr009. The protocol clearly states that the nurse should seek a doctor s input if any concern surrounding circumstances of death exists. NHS Emergency Ambulance staff can also Recognise Life Extinct. This route of confirmation should not be used for expected deaths. Withholding CPR from someone not subject to a DNACPR order CPR may be withheld by any individual who deems that CPR would be futile owing to the victim s injury or underlying mechanism of trauma. In any circumstances of doubt, CPR should be commenced. CPR may be withheld from an individual in the absence of a DNACPR order if they are in the final stages of a terminal illness where death is inevitable and CPR would not be successful.* Application of CPR in these circumstances may be regarded as undignified or degrading can be profoundly distressing for relatives. * There will be some patients for whom attempting CPR is clearly inappropriate; for example a patient in the final stages of a terminal illness where death is imminent and unavoidable and CPR would not be successful, but for whom no formal DNACPR decision has been made. In such circumstances, healthcare workers who make a considered decision not 17

18 to commence CPR should be supported by their senior colleagues and employers. Decisions relating to cardiopulmonary resuscitation: A joint statement from the BMA, RC(UK) and the RCN 3 rd Edition (2014). Care of the deceased Where the decision has been made to allow natural death, the patient will be treated with dignity and respect. Last offices should be carried out as appropriate. Family members and carers may find involvement in this process therapeutic and should be offered comfort, advice and support. Arrangements should be made for collection of the deceased. The individual should never be left in an undignified manner, and should death take place in a public area, they should be immediately covered and (except in potentially suspicious circumstances) quickly removed to an appropriate place. Training requirements associated with this Policy Mandatory Training Training required to fulfil this policy will be provided in accordance with the Trust s Training Needs Analysis. Management of training will be in accordance with the Trust s Statutory and Mandatory Training Policy Specific Training not covered by Mandatory Training Ad hoc training sessions based on an individual s training needs as defined within their annual appraisal or job description How this Policy will be monitored for compliance and effectiveness The table below outlines the Trust's monitoring arrangements for this document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. 18

19 Aspect of compliance or effectiveness being monitored Method of monitoring Individual responsible for the monitoring Monitoring frequency Group or committee who receive the findings or report Group or committee or individual responsible for completing any actions Duties DNACPR orders and compliance with clinical records keeping will be carried out using the DNACPR order sheets as a data source Staff have completed training associated with this policy in line with the TNA To be addressed by the monitoring activities below. Audit of 5 Resuscitation Annually Quality DNACPR orders Officer Forum and Clinical Governance Resuscitation Officer Training will be monitored in line with the Statutory and Mandatory Training Policy. For further information Please contact the Medical Director or Resuscitation Lead No further references, bibliography or weblinks are provided for this Policy. Equality considerations The Trust has a duty under the Equality Act and the Public Sector Equality Duty to assess the impact of Policy changes for different groups within the community. In particular, the Trust is required to assess the impact (both positive and negative) for a number of protected characteristics including: Age; Disability; Gender reassignment; Marriage and civil partnership; Race; Religion or belief; 19

20 Sexual orientation; Pregnancy and maternity; and Other excluded groups and/or those with multiple and social deprivation (for example carers, transient communities, ex-offenders, asylum seekers, sex-workers and homeless people). The author has considered the impact on these groups of the adoption of this Policy and the assessment report is contained at the end of this policy. Reference Guide British Medical Association, Resuscitation Council (UK), Royal College of Nursing. October 2014 Decisions relating to Cardiopulmonary resuscitation: a joint statement from the BMA, RC(UK) & RCN, 3 rd Edition Mental Capacity Act 2005: Implementation Guidance Cardiopulmonary resuscitation standards for clinical practice and training: A Joint Statement from the Royal College of Anaesthetists, the Royal College of Physicians of London, the Intensive Care Society and the Resuscitation Council (UK). October 2004 East Midlands Children and Young People EOL Strategy East Midlands Ambulance NHS Trust / SHA East Midlands Regional Personal Resuscitation Plan for Children. East Midlands Ambulance NHS Trust / SHA. September East Midlands unified DNACPR Form. East Midlands Ambulance NHS Trust. January East Midlands unified DNACPR Principles. East Midlands Ambulance NHS Trust. January Guidance for Clinical Practice and Training in Primary Care (July 2001) Health Service Circular HSC 2000/028: Resuscitation Policy NHSLA Risk Management Draft Standards For Primary Care Trusts (NHSLA 2007) Human Rights Act, The Stationery Office. October 2000 The Legal Status of Those who Attempt Resuscitation, Resuscitation Council UK 2010 Mental Capacity Act 2005: Mental Capacity Act 2005 Code of Practice: NCEPOD Cardiac Arrest Procedures: Time to intervene? 2012 NHSLA Pilot Risk Management Standards. Standard 4 Criterion 8: The Deteriorating Patient. NHS Litigation Authority January

21 NICE Quality Standard 13: End of Life care for Adults NHS Executive Resuscitation Policy (HSC 2000/028) September 2000 Nursing & Midwifery Council. The Code. (2015) Resuscitation Council (UK) (2015) Advanced Life Support Manual (7th Ed). Tracey (2014) Treatment and care Towards the End of Life: Good practice in Decision Making. GMC. (2010) Wenger, N.S. Phillips, R.S. Teno, J.M. Oye, R.K. Dawson, N.V. Liu, H. Califf, R. Layde, P. Hakim, R. Lynn, J. Physician understanding of patient resuscitation preferences: insights and clinical implications (2000) Journal of the American Geriatrics Society 48 (5 Suppl): S44-51 Document control details Author: Sessional Resuscitation Officer Approved by and date: Trust Policy Board Responsible Committee Quality Forum Any other linked Policies: CLP002 - Resuscitation and Related Medical Emergencies Policy CLP023 - Mental Capacity Act 2005 Policy CLP009 - Nurse verification of Death Protocol Policy number: CLP054 Version control: Version 4: Version No. Date Ratified/ Amended Date of Implementation Next Review Date Reason for Change (eg. full rewrite, amendment to reflect new legislation, updated flowchart, minor amendments, etc.) Complies with and enshrines East Midlands Regional Guidance on decisions surrounding resuscitation and the judgement Tracey v Cambridgeshire NHS (2014) New governance of trust policies template. 21

22 APPENDIX 1 DNACPR Form AND DECISION FRAMEWORK PAGE INTENTIONALLY LEFT BLANK. SEE FOLLOWING PAGES FOR CONTENT. 22

23 DNACR Form Document below Do Not Attempt Cardiopulmonary Res The form is also available by the link on the homepage of the Hub. 23

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25 APPENDIX 2 PERSONAL RESUSCITATION PLANS The PRP is a large document, please access the current version via the internet ***Go to and click on the Link for Children s PRPs to download the current version*** [Type text]

26 APPENDIX 3 PERSONAL RESUSCITATION PLAN COMMUNICATION PROCEDURES Procedures for making and communicating Children / Young People s Personal Resuscitation Plans, in Northamptonshire. Consultant Paediatrician (or GP) completes and signs the plan (or review of the plan). The plan must be reviewed at least every 12 months. Indicate phone numbers of professionals on the plan who can give information to the ambulance crew. This should include relevant nursing teams, doctors, and out of hours services. Ensure that all relevant places have an original copy (signed originally by doctor, parents and others required to sign) These will include home, children s community nursing teams (as appropriate), respite care, school, nursery, child minder, planned admission hospital and any other location where the child normally resides or spends significant amounts of time. Copies MUST have ORIGINAL signatures on them. Photocopied signatures are NOT acceptable. Communication sequence. 1. Advise families that they must carry their plan with them at all times and to ensure they inform the 999 operator of its existence. 2. Copy to GP. (If plan originated by GP, copy to Consultant Paediatrician) 3. Fax a copy to Northamptonshire Out of Hours doctors service (Fax ) 4. a copy to Northamptonshire police for them to inform their staff (also accessible by the Coroner) PVPReferralUnit@northants.pnn.police.uk

27 APPENDIX 4 - COMMUNICATION FLOWCHART This flowchart is intended to give doctors and senior nursing staff a guide as to who DNACPR decisions should be discussed with, and who should be informed of the decision. Does the patient have capacity? Yes No Would involvement in end of life discussions HARM the patient? Is the patient capable of contributing to discussions? No Yes No Yes Has the patient stated they do not want to discuss DNACPR? Would involvement in end of life discussions HARM the patient? No Yes Yes No Involve the patient. Do not involve the patient. Involve the patient. Does the patient consent to their family being involved? No Yes Are the family willing to be involved? Yes No Are the family willing to be involved? No Yes Do not involve the family. Do not involve the family. Involve the family. Consider IMCA

28 The second flowchart guides doctors and senior nursing staff to whom DNACPR decisions should be disclosed to. Does the patient have capacity? Yes No Would disclosure of the DNACPR HARM the patient? Is the patient capable of understanding the DNACPR? No Yes No Yes Has the patient stated they do not want to be informed of any DNACPR decision? Would disclosure of the DNACPR HARM the patient? No Yes Yes No Involve the patient. Do not inform the patient. Inform the patient. Does the patient consent to their family being informed? Do the family wish to be informed? No Yes Yes No Do the family wish to be informed? No Yes Do not inform the family. Do not inform the family. Inform the family.

29 APPENDIX 5 - INFORMATION FOR PATIENTS AND CARERS As a patient, you have a right to be involved in all decisions relating to your care including those about end of life treatment and attempting to restart your heart and your breathing if they stop. You also have a right not to be involved in these discussions if you do not wish to do so. Your doctors and other health professionals will give you the information you need to be able to make a good decision with them about what treatment would be appropriate for you. Your healthcare professionals will give you honest and open advice about what course of treatment they think is suitable and will give you an honest opinion about whether attempted resuscitation would be successful. You will be given information about what types of treatment are available at the end of life (palliative care) to ensure that you do not have any pain or discomfort. For many people attempted resuscitation is useful, most often in people (of any age) who are generally fit and well and have not been diagnosed with a life limiting or terminal condition. Attempted resuscitation - the delivery of chest compressions and artificial breathing coupled with electric shocks (defibrillation) is of most benefit to people who have a sudden heart problem, something like a heart attack. For these people, the quick application of resuscitation can save their life. However, many people are diagnosed with conditions which will ultimately lead to them dying. These conditions could be cancer, or lung problems, heart problems, failing kidneys or dementia. In these cases, once the condition has become very advanced, attempted resuscitation is unlikely to be very helpful. The conditions or diseases often make the person so unwell that they will not survive after resuscitation is attempted. Equally, some people may be brought back to a very poor quality of life that may be very distressing for them, their family and their friends. For people with such conditions, there will come a time where a decision whether to attempt resuscitation or not will need to be made. It is not a indication that you will be abandoned, far from it. Many different treatments will be offered to make sure that you are comfortable in the last weeks and days of your life. It is merely a shift in focus from doing all we can to preserve life to doing all we can to prevent any pain or distress. If a Do Not Attempt Cardiopulmonary Resuscitation decision is put into place, this will not affect any other care that you receive. You will still have any treatments that are appropriate, and you will still be given food and drink. All the decision means is that when your heart and lungs naturally cease to function, we won't do anything to try and start them working again. Your family also can be involved in the decision-making process if you would like them to, and they can also be told about what is happening with your care, again if you would like them to be told about this. You can ask that your family speak for you if you'd rather not be involved in the discussions we need to have about your future care.

30 Equality Analysis Report Equality Analysis Report Name of function: Do Not Attempt Cardiopulmonary Resuscitation Policy Date: January 2015 Assessing officers: Description of policy including the aims and objectives of proposed: (service review/resign, strategy, procedure, project, programme, budget, or work being undertaken): This policy has been drafted to comply with the Human Rights Act and all individual decisions made about CPR. The spirit of the Act, which the policy reflects aims to protect the patient by promoting human dignity and transparent decision making. Prolonging a patient s life usually provides a health benefit to that patient. Nevertheless, it is not appropriate to prolong life at all costs with no regard to its quality or to the potential burdens of treatment for the patient. The aim of the policy therefore is concerned with: Patient choice and respect for the choices they make Maximising health and minimising harm; Ensuring that decisions about CPR are made on the basis of an individual assessment of each patient s case Evidence and Impact provide details data community, service data, workforce information and data relating specific protected groups. Include details consultation and engagement with protected groups. Evidence base: NHFT Equality Information Report August 2012 Northampton County Council :Northamptonshire Results: 2011 Census Data Summary Corby Daventry East Northants Kettering Northampton South Northants Wellingborough Northants 53,400 72,100 76,600 82, ,200 79,400 72, , ,100 77,700 86,800 93, ,100 85,200 75, ,900 % rise 14.4% 7.8% 13.3% 13.7% 9.2% 7.3% 4.0% 9.8% Ethnicity: 85.7% (White) and 14.3% (BME )- 1.75% (dual heritage); 4.01% (Asian); 2.5%(Black Page 30 of 32