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1 Document Type: Procedure Document Title: Do Not Attempt Cardio-Pulmonary Resuscitation Scope: Trust Wide Author / Title: Kate Casey, Senior Manager Replaces: Version 3, Policy for Do not Attempt Cardio-Pulmonary Resuscitation MED3, CORP/PROC/019 Validated By: Acutely Ill and Resuscitation Group Ratified By: Procedural Documents and Information Leaflet Group Review dates may alter if any significant changes are made Unique Identifier: CORP/PROC/019 Version Number: 3.1 Status: Ratified Classification: Organisational Responsibility: Critical Care Head of Department: Dr. P Grout, Clinical Director Date: 04/02/2015 Date: 20/05/2015 Review Date: 01/03/2018 Which Principles of the NHS Constitution Apply? Please list from principles 1-7 which apply 1,2,3,4,5 Which Staff Pledges of the NHS Constitution Apply? Please list from staff pledges 1-7 which apply 1 Does this document meet the requirements of the Equality Act 2010 in relation to Race, Religion and Belief, Age, Disability, Gender, Sexual Orientation, Gender Identity, Pregnancy & Maternity, Marriage and Civil Partnership, Carers, Human Rights and Social Economic Deprivation discrimination? Yes Document for Public Display: Yes Reference Check Completed by Frances Sim..Date To be completed by Library and Knowledge Services Staff

2 CONTENTS Page BEHAVIOURAL STANDARDS FRAMEWORK 3 1 SUMMARY 4 2 PURPOSE 4 3 SCOPE 5 4 PROCEDURE (for example) Duties DNACPR / DNAR DNACPR Documentation Resuscitation Status Making Decisions Suspension of DNACPR Decision Reversal of a DNACPR Decision Communication Mental Capacity Act Transferring a Patient with a DNACPR Advance Decisions to Refuse Treatment (ADRT) Review of DNACPR Decisions Infants, Children and Young People Monitoring Compliance Standards / KPIs 12 5 ATTACHMENTS 12 6 OTHER RELEVANT / ASSOCIATED DOCUMENTS 12 7 SUPPORTING REFERENCES / EVIDENCE BASED 13 DOCUMENTS 8 DEFINITIONS / GLOSSARY OF TERMS 13 9 CONSULTATION WITH STAFF AND PATIENTS DISTRIBUTION PLAN TRAINING AMENDMENT HISTORY 15 Appendix 1 Deciding Right DNACPR Form 16 Appendix 2 udnacpr Form 18 Appendix 3 DNACPR Patient Information Leaflet 20 Appendix 4 Resuscitation Plan for Children 23 Appendix 5 Equality and Diversity Impact Assessment Tool 25 Page 2 of 25

3 BEHAVIOURAL STANDARDS FRAMEWORK To help create a great place to work and a great place to be cared for, it is essential that our Trust policies, procedures and processes support our values and behaviours. This document, when used effectively, can help promote a workplace culture that values the contribution of everyone, shows support for staff as well as patients, recognises and celebrates the diversity of our staff, shows respect for everyone and ensures all our actions contribute to safe care and a safe working environment - all of which are principles of our Behavioural Standards Framework. Behavioural Standards Framework Expectations at a glance Introduce yourself with #hello my name is... Value the contribution of everyone Share learning with others Be friendly and welcoming Team working across all areas Recognise diversity and celebrate this Respect shown to everyone Seek out and act on feedback Ensure all our actions contribute to safe care and a safe working environment Put patients at the centre of all we do Be open and honest For those who supervise / manage teams: ensure consistency and fairness in your approach Show support to both staff and patients Communicate effectively: listen to others and seek clarity when needed Be proud of the role you do and how this contributes to patient care

4 1. SUMMARY This procedure has been developed in collaboration with the Cumbria Partnership NHS Foundation Trust and the North West Ambulance Service. This procedure applies to all health and social care teams involved in patient care within University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBFT). All health and social care professionals should be aware of their patients DNACPR status; furthermore, staff have a responsibility and should be encouraged to be involved in the DNACPR decisionmaking process. The responsibility for making decisions is that of the senior clinicians responsible for the patient s care. This procedure is intended as a positive step to help a person s wishes in regard to cardio-pulmonary resuscitation (CPR). The primary goal of healthcare is to benefit patients by maintaining their health as far as possible, thereby maximising benefit and minimising harm. If treatment fails, or ceases to benefit the patient, or if an adult patient with capacity has refused treatment, that treatment is no longer justified. CPR is undertaken in an attempt to restore breathing and spontaneous circulation in a patient in cardiac and/or respiratory arrest. This is invasive and can involve electric shocks, the insertion of breathing tubes, vigorous chest compressions and the injection of drugs. 2. PURPOSE The procedure is intended to ensure that appropriate attempts at CPR are undertaken, thus minimising distress to patients, their loved ones and indeed the resuscitation teams. A death with inappropriate CPR attempt may be undignified and not have been as the patient and those close to them would have wished. Implementation of the procedure will lead to: facilitation of open, appropriate and realistic discussions with patients and relevant others about resuscitation issues clarification that DNACPR refers only to resuscitation and NOT to other elements of care and treatment a consistent and integrated approach to DNACPR decision-making clarification of the decision-making process for clinical staff caring for people who have communication difficulties, and other vulnerable groups improved documentation of all decisions and discussions, and that these are communicated to all health and social care workers involved in patients care decisions regarding CPR being made taking into account: o o o whether CPR could succeed the clinical needs of the patient the patient s and parent s or carer s wishes

5 o o current ethical principles legislation such as the Human Rights Act (1998) 1 and the Mental Capacity Act (2005) 2 (England and Wales) DNACPR decisions being transparent and open to examination in hospital through means such as clinical audit the encouragement and facilitation of open, appropriate and realistic discussion with patients and their relevant others about resuscitation issues all discussions/decisions being clearly documented and communicated to all health and social care workers involved in patient care. 3. SCOPE Applies to all staff who: o Consider a patients resuscitation status o Complete a DNACPR forms (GMC Registered Medical Staff) o Clinical Staff who communicate plans of patient care 4. PROCEDURE 4.1 Duties Trust Board Responsibilities include: receiving regular reports from the Quality Committee receiving and discussing minutes from the Quality Committee Quality Committee Responsibilities include: receiving regular reports from the Acutely Ill and Resuscitation Group receiving and discussing minutes from the Acutely Ill and Resuscitation Group Acutely Ill and Resuscitation Group Responsibilities include: ensuring that the audit process is occurring and reviewing the results with follow-up recommendations and action plan reviewing the resuscitation policies at least every 3 years and feeding back findings on the resuscitation service to the Quality Committee Clinicians The person who makes a DNACPR decision is responsible for ensuring that the decision Page 5 of 25

6 is communicated effectively to other relevant health and social care professionals, adult patient, young person or person with parental responsibility (see making decisions 4.5 and communication 4.8). Once the DNACPR decision is made and the form completed this is to be recorded in the patient s case notes and on the electronic patient record (EPR). In situations when a DNACPR decision is reversed this must be communicated and recorded in the patient s case notes and on the electronic patient record (EPR). Clinicians MUST accurately and fully complete the DNACPR form, including where information relating to discussions held is documented. Clinicians may be asked to justify their decision Senior Nurse The senior nurse is responsible for making sure the decision is recorded in the nursing notes if these are separate from the medical notes Resuscitation Officers The Resuscitation Officers will audit compliance with the procedure on an annual basis and report their findings to the Acutely Ill and Resuscitation Group. The Resuscitation Officers will bring the DNACPR procedure and the form to the attention of all staff on induction programmes and all life supporting training. 4.2 DNACPR / DNAR This procedure is using the term Do not attempt cardio-pulmonary resuscitation rather than just Do not attempt resuscitation (DNAR); this is to clarify for patients, families and professionals that it relates solely to cardio-pulmonary resuscitation. It does not relate to other aspects of care such as analgesia, antibiotics, suction, and treatment of choking or anaphylaxis which can sometimes be loosely referred to as resuscitation. This is often an area of concern and should be made explicit in discussions on DNACPR. 4.3 DNACPR Documentation Deciding Right North of England SCN, udnacpr North West SCN 3 Healthcare professionals have an important role in helping patients to participate in making appropriate plans for their future care in a sensitive but realistic manner; this includes the rationale for making a DNACPR decision. UHMBFT has agreed to adopt the Deciding Right DNACPR form (Appendix 1). The decision must be reviewed within 12 months. Service providers across the North West have agreed to implement the udnacpr form (Appendix 2). Patients may be admitted from community settings with either of these forms, when accurately completed both are to be recognised within UHMBFT. 4.4 Resuscitation Status All patients resuscitation status should be considered when they are acutely unwell and become medically unstable. In addition, clinicians should consider anticipatory decisions Page 6 of 25

7 about CPR as an integral part of delivering high-quality and compassionate end-of-life care for their patients. The status should be considered as soon as is reasonably possible if a cardio-pulmonary arrest can be anticipated. The patient s individual circumstances and current guidance must be carefully considered with involvement of the patient and (where appropriate) those close to them before a decision is made. 4.5 Making Decisions The ultimate responsibility for a DNACPR decision rests with the senior medical practitioner (Consultant or GP) responsible for the patient s care. The DNACPR form is to be utilised by and readily accessible to all agencies, the original is to be kept in patient s care setting. When a clinical decision is made that CPR should not be attempted, because it would not be successful clinicians should explain this to patients and those close to them at the earliest possible time, unless such explanation is contrary to the patient s expressed wishes or clinicians believe that explaining the decision to the patient would be physically or psychologically harmful. If the patient lacks capacity, clinicians should inform any legal proxy and others close to the patient about the DNACPR decision and the reasons for it. This should be recorded on the DNACPR form. Only in exceptional circumstances should a patient s condition deteriorate sufficiently rapidly for a DNACPR decision to be applied before there has been an opportunity to inform the family of a patient who lacks capacity. Where a DNACPR decision is made on the grounds that CPR would not be successful, and a patient or their representative does not accept that decision, a second opinion should be offered. Sometimes CPR may be successful, but the benefits of prolonging life may be outweighed by the potential burdens and risks. In such cases, a DNACPR is not solely a clinical decision and the clinicians are under a duty to consult the patient unless they believe this is likely to cause physical or psychological harm. Many patients may find it distressing to discuss the question of whether CPR should be withheld from them in the event of a cardiorespiratory arrest but distress must be likely to cause the patient a degree of harm to warrant them not having the decision discussed with or explained to them. Discussion with patients about whether CPR should be attempted must be approached sensitively and with support for the patient if required. The patient should be provided with accurate information about the burdens and risk of CPR, including the likely outcomes if it is successful and the extent to which other intensive treatments may not be considered clinically appropriate after successful CPR. Some patients may wish to receive CPR when there is only a small chance of success, in spite of the risk of distressing clinical and other outcomes. When the benefits, burdens and risk are finely balanced, the patient s request will usually be the deciding factor. In the unusual circumstance in which the doctor responsible for a patient s care feels unable to agree to that patient s request to receive attempted CPR, or where there is a lack of agreement within the healthcare team, a second opinion should be sought. If a patient lacks capacity to make a decision about future CPR, clinicians should consult Page 7 of 25

8 any legal proxy with appropriate authority. If there is no legal proxy, the issue must be discussed with those close to the patient (unless, when they were previously competent to do so, an adult patient has expressed a wish that information be withheld from them) and the healthcare team and account taken of any previously-expressed wishes of the patient. The decision should be made in accordance with the Mental Capacity Act When no explicit decision has been made about DNACPR before a cardio-pulmonary arrest occurs, and the express wishes of the patient are unknown, it should be presumed that staff would commence CPR. However, where CPR would clearly fail (for example, a patient in the final stages of a terminal illness where death is imminent and expected) it should not be attempted; a qualified medical practitioner consultation with a responsible clinician may make and record a considered decision which ought to be supported by their colleagues. If not initially signed by the senior responsible clinician (Consultant or GP), the form must be countersigned at the next available opportunity. Any DNACPR decision must be tailored to the individual circumstances of the patient. Healthcare professionals must not base a decision on their own subjective assumptions about age or disability or a patient s quality of life. When a patient has an implantable cardioverter defibrillator (ICD), refer to section 3.5 of the Implantable Cardioverter Defibrillator (ICD) Reprogramming Guidelines (Switch Off (Withdrawal of Therapy) of Device due End Stage Heart Failure). 4.6 Suspension of DNACPR Decision Temporary suspension of a DNACPR decision may be appropriate if a procedure could precipitate a cardio-pulmonary arrest, for example, cardiac catheterisation, pacemaker insertion or surgical operations. Similarly, some patients for whom a DNACPR decision has been established may develop cardiac or respiratory arrest from a readily reversible cause such as choking, induction of anaesthesia, anaphylaxis or blocked tracheostomy tube; in such situations resuscitation processes would be appropriate until the reversible cause is treated, unless the patient has specifically refused intervention in these circumstances. Earlier individualised discussions with patients about their care should have addressed this and their wishes for a dignified and peaceful death respected. When a patient is in the final stages of an incurable illness and death is expected within a few days, CPR is very unlikely to be clinically successful. 4.7 Reversal of DNACPR Decision In situations when a DNACPR decision is reversed, for example where a patient has responded to treatment and the clinical judgement is that CPR would no longer be medically futile; this must be effectively communicated and recorded The process for this is making a written entry in the patient s case notes, writing across the form NO LONGER VALID which must be dated and signed and on the EPR the DNACPR must be struck out. Page 8 of 25

9 4.8 Communication It is not the healthcare professional s responsibility to decide how much information the adult patient, young person or person with parental responsibility should receive; their task is to find out how much the patient wishes to know or can understand. The decision must be the one that is right for the patient and information should never be withheld because conveying it is difficult or uncomfortable for the healthcare team. It must be made clear to the adult patient, young person or person with parental responsibility and relevant others that a DNACPR decision does NOT apply to other aspects of treatment and that all other appropriate treatment and care will continue. Neither adult patients, young people or people with parental responsibility nor those close to them, can demand treatment that is clinically inappropriate. If the healthcare team believes that CPR will not re-start the heart and breathing, this should be explained to the adult patient in a sensitive way. Informing the adult patient, young person or person with parental responsibility of the healthcare team s decision may be difficult and where possible should be carried out by experienced senior clinicians. If the adult patient, young person or person with parental responsibility does not accept the decision they should be informed that a second opinion can be arranged for them. Any discussions with a patient, or those close to them, about whether to attempt CPR, and any decisions made, should be documented in the patient s record. If a DNACPR decision is made and there has been no discussion with the patient because they indicated a wish to avoid it, or because it was the clinician s considered view that discussion with the patient was not appropriate, this should be noted in the patient s records. Patients, relatives and their carers are to be offered written information about DNACPR decisions. The Trust preferred information leaflet is contained in Appendix 3. That the offer of written information has been made ant the uptake of this is to be recorded in the patients medical notes. 4.9 Mental Capacity Act The Mental Capacity Act allows people over the age of 18 who have capacity to make a lasting power of attorney (LPA), appointing a welfare attorney to make health and personal welfare decisions on their behalf once such capacity is lost. Welfare attorneys cannot demand treatment that is clinically inappropriate. Decision-making capacity refers to the ability that individuals possess to make the specific decision in question. Adult patients are presumed to have capacity to make decisions for themselves unless there is evidence to the contrary that is, they are unable to: understand the information relevant to the decision and retain that information use or weigh that information as part of the process of making decisions communicate the decision (whether by talking, sign language, visual aids or other means) For those adults who lack capacity and have neither an attorney nor an advance Page 9 of 25

10 directive, but have family or friends, the clinician should assess best interests by seeking the views of those close to the patient. Those who lack capacity and have no family, friend or advocate should have an independent mental capacity advocate (IMCA). The IMCA should be consulted about serious medical treatment and DNACPR comes under that remit Transferring a Patient with a DNACPR Any decisions about CPR should be communicated between healthcare professionals whenever a patient is transferred. Clinical guidelines issued by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) advise ambulance staff that they should always initiate CPR unless: there is a formal DNACPR decision, or valid and applicable advance decision made by the patient, which has been seen by the ambulance crew, and the circumstance in which CPR may be attempted are consistent with the wording of the DNACPR decision or advance decision the patient is known to be terminally ill and is being transferred to a palliative or terminal care facility (unless specific instructions have been received that CPR should be attempted) To enable ambulance staff to comply with these guidelines, procedures are in place to notify the ambulance staff of patients CPR status, and provide them with the necessary documentation before the journey commences Advance Decisions to Refuse Treatment (ADRT) CPR must not be attempted if it is contrary to valid and applicable advance decisions made when patients had capacity. In England, advance decisions are covered by the Mental Capacity Act The act confirms that an advance decision refusing CPR will be valid and therefore legally binding on the healthcare team, if: the patient was 18 years old or over and had capacity when the decision was made the decision is in writing, signed and witnessed it includes a statement that the advance decision is to apply even when the patient s life is at risk the advance decision has not been withdrawn the patient has not, since the advance decision was made, appointed a welfare attorney to make decision about CPR on their behalf the circumstances that have arisen match those envisaged in the advance decision Page 10 of 25

11 If an advance decision does not meet these criteria but appears to set out a clear indication of the patient s wishes, it will not be legally binding but should be taken into consideration in determining the patient s wishes 4.12 Review of DNACPR Decisions Decisions about CPR must be reviewed within 12 months and whenever changes occur in a patient s condition or in the patient s expressed wishes. The frequency of review should be determined by the senior medical practitioner responsible for the patient care and will be influenced by the clinical circumstances of the patient. The DNACPR decision will be valid when moving between the community and other healthcare organisations within Cumbria and Lancashire North. For example, if a GP has made a DNACPR decision and a patient has been admitted to hospital that decision remains intact but may be reviewed under changing circumstances Infants, Children and Young People Ideally, clinical decisions relating to infants, children and young people should be taken within a supportive partnership involving patients, their families and the healthcare team. Where CPR may re-start the heart and breathing for a sustained period but there are doubts about whether the potential benefits outweigh the burdens, the views of the child or young person should be taken into consideration in deciding whether it should be attempted. Young people with capacity are entitled to give consent to medical treatment, and where they lack this capacity, it is generally those with parental responsibility who make decisions on their behalf. In England, refusal of treatment by competent young people up to the age of 18 is not necessarily binding upon doctors since the courts have ruled that consent from people with parental responsibility, or the court, still allows doctors to provide treatment. Where a young person with capacity refuses treatment, the potential harm caused by violating the young person s choice must be balanced against the harm caused by failing to give treatment. Usually it is possible to reach agreement on whether or not CPR should be attempted if an infant, child or young person suffers respiratory or cardiac arrest. If there is disagreement between the patient, those with parental responsibility and the healthcare team despite attempts to reach agreement, legal advice should be sought. Parents cannot require doctors to provide treatment contrary to their professional judgement, but doctors should try to accommodate parent s wishes where there is a genuine uncertainty about the young person s best interests. If legal advice is required, this should be sought in a timely manner. The Children s Resuscitation Plan template (Appendix 4) is used to document the plan regarding resuscitation for any child for whom the standard approach is not applicable. The plan is only put in place in full consultation with parents or carers and should be reviewed on a regular basis. Page 11 of 25

12 4.14 Monitoring Compliance Adherence to this procedure will be reported to the trust s resuscitation group through annual clinical audit. Monitoring will be undertaken by the senior resuscitation officer and the resuscitation department team. Findings will be reported to the resuscitation group. Requirement Method Frequency Lead Monitoring Group To assess compliance with the procedure Auditing DNACPR forms in relation to the procedure 4.15 Standards / KPIs Annual Resuscitation Officer Audit lead Resuscitation Dept. All resuscitation decisions will be recorded on the correct form. Action plan lead Resuscitation Officer Audit lead Committee/ group overseeing Action Plan Resuscitation Group Resuscitation decisions should be documented by a senior clinician and their name must be clearly legible. The rationale for a DNACPR decision must be recorded. All discussions about DNACPR must be documented. If discussion did not take place, the reasons for this must be clearly outlined. Adherence to the procedure may also be periodically audited by the internal audit department as part of the review of internal controls. 5. ATTACHMENTS Number Title 1 Deciding Right DNACPR Form 2 udnacpr Form 3 DNACPR Patient Information Leaflet 4 Resuscitation Plan for Children 5 Equality and Diversity Impact Assessment Tool 6. OTHER RELEVANT / ASSOCIATED DOCUMENTS Unique Identifier Title and web links from the document library Page 12 of 25

13 7. SUPPORTING REFERENCES / EVIDENCE BASED DOCUMENTS References in full Numbe References r 1 Great Britain (1998) Human Rights Act Available from: (accessed ) 2 Great Britain (2005) Mental Capacity Act Available from: (accessed ) 3 NHS England. Northern Clinical Networks and Senate. (2014) Deciding right. Your life. Your choice: an integrated approach to making care decisions in advance with children, young people and adults. Available on from: (accessed ) Bibliography Decisions relating to cardio-pulmonary resuscitation: A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. (3 rd Ed) 2014 Available online at: (accessed ) NHS Scotland (2010) Do not attempt cardiopulmonary resuscitation : Integrated Adult Policy. Edinburgh: The Scottish Government. Available online from: (accessed ) General Medical Council (GMC) (2010) Treatment and care towards the end of life: good practice in decision making. Available online from: English_0515.pdf_ pdf (accessed ) DoH (2007)The Mental Capacity Act Code of Practice. Available online from: (accessed ) Resuscitation Council (UK) Quality standards for cardiopulmonary resuscitation and training. Available online from: (accessed ) Joint Royal Colleges Ambulance Liaison Committee (2013) UK Ambulance Servcies Clinical Practice Guidelines Available from: (accessed ) 8. DEFINITIONS / GLOSSARY OF TERMS Abbreviation Definition or Term CPR Cardio-pulmonary resuscitation DNACPR Do Not Attempt Cardio-pulmonary resuscitation ICD Implantable cardioverter defibrillator IMCA Independent mental capacity advocate JRCALC Joint Royal College Ambulance Liaison Committee LPA Lasting power of attorney SRO Senior Resuscitation Officer Page 13 of 25

14 9. CONSULTATION WITH STAFF AND PATIENTS Enter the names and job titles of staff and stakeholders that have contributed to the document Name Job Title Lucy Belson Senior Resuscitation Officer (left UHMBT May 2013) Kate Casey Head of the KELD (Knowledge Education Learning & Development) Division Alison Scott End of Life Lead Nurse Joanne Connolly Practice Educator / Acting Deputy Lead Nurse for Children and Young People Fiona Rainsford Interim Matron / Practice Educator Melanie Woolfall Advanced Practitioner Acute Care, Surgery & Critical Care Ranu Rowan Head of Legal Services Sharon Thomas Hill Dickinson Solicitors Cumbria Partnership NHS Foundation Trust NWAS 10. DISTRIBUTION PLAN Dissemination lead: Previous document already being used? If yes, in what format and where? Proposed action to retrieve out-of-date copies of the document: To be disseminated to: Document Library Proposed actions to communicate the document contents to staff: Alison Scott Yes Electronically on Heritage Replace on Heritage. Update link on Communications page and add link to Heritage Include in the UHMB Weekly News New documents uploaded to the Document Library 11. TRAINING Is training required to be given due to the introduction of this procedural document? *Yes / No Please delete as appropriate Action by Action required Implementation Date Page 14 of 25

15 12. AMENDMENT HISTORY Revision Date of Page/Selection Description of Change Review Date No. Issue Changed 1.0 Sept All Reformatted to comply to Sept trust policy 2.0 Feb Content for children s Feb 2016 services updated 2.1 Jan Reference to Liverpool Care Pathway Removed Feb ICD Guidelines from Cardiac and Stroke Network (Blackpool Teaching Hospital NHS Foundation Trust) incorporated Minor amendments to wording throughout document to clarify roles. 3 Feb Updated to reflect recent Mar case-law 3.1 Oct 2017 Page 3 BSF Addeds Mar 2018 Page 15 of 25

16 Appendix 1: Deciding Right DNACPR Form Page 16 of 25

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18 Appendix 2: udnacpr Form Page 18 of 25

19 Page 19 of 25

20 Appendix 3: DNACPR Patient Information Leaflet Page 20 of 25

21 Page 21 of 25

22 Page 22 of 25

23 Appendix 4 Resuscitation Plan for Children Page 23 of 25

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25 Appendix 5: EQUALITY & DIVERSITY IMPACT ASSESSMENT TOOL Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems No No No No No No No No No 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination are there any exceptions - valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? Not Applicable Not Applicable Not Applicable 4.a If so can the impact be avoided? Not Applicable 4.b What alternative are there to achieving the policy/guidance without the impact? 4.c Can we reduce the impact by taking different action? Not Applicable Not Applicable If you have identified a potential discriminatory impact of this procedural document, please refer it to the HR Equality & Diversity Specialist, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the HR Equality & Diversity Specialist, Extension Page 25 of 25