Where we came from, Where we are & What s next

Transcription

1 Where we came from, Where we are & What s next Dr. Zoë Fritz Chair of Strategic Steering Group for Consultant Physician, Acute Medicine, Cambridge Wellcome Fellow in Society and Ethics

2 First, a reminder / recap: DN.the acronym which loved to get longer DNR DNAR DNACPR DNARUTIASRWACRC;AOTSBG

3 DNACPR A few issues 1. Not routinely completed (Cohn et al Q J Med 2013) 2. Inappropriate Resus Attempts (NCEPOD 2012 Time to Intervene) 3. No one likes discussing this (Sivakumar et al J Med Ethics 2004) (So people didn t) R (Tracey) v CUH NHS Foundation Trust & Ors [2014] EWCA Civ Misunderstood (Fritz et al Resuscitation 2010)

4 DNACPR and a couple more issues 5. Difference in care (Chen JL, et al 2008, Cohen RI, et al 2009, Brizzi M, et al 2012, Kazaure H, et al 2011, Moffat S et al 2016) 6. Variation in approach (Clements et al 2014 )

5 What to do about all of these problems? An ethical imperative to stop using DNACPR But Replace it with what? And test it how?

6 Development of Stakeholders from 37 different patient and clinical group review of evidence of best practice nationally and internationally UFTO, TEP, Deciding Right, the Unwell Patient, POLST, MOST 26 iterations via adapted Delphi method Public Consultation had over 1000 responses, 91% agreed with the principles Usability testing, 22 further iterations and change of title Further usability testing in 5 sites NIHR Grant to evaluate in early adopter sites

7 The Process what s involved 1. Establish shared understanding of current situation 2. Discuss preferred outcomes

8 BMJ 2017; 356 doi:

9 BMJ 2017; 356 doi:

10 The Process what s involved 1. Recommend treatments likely to result in these outcomes 2. Record recommendations in a readily recognised format. 3. CPR decision in context of overall goals of care

11 Change to what s needed? A change of culture from: health and care professionals members of the public Not just another change in acronym!

12 who is it for? Everyone, with increasing relevance for those: with particular healthcare needs nearing the end of their lives or at risk of cardiac arrest who want to record their preferences for any reason Best completed when a person is relatively well Can still ( obviously) be completed in an emergency if needed!

13 The past is prologue.

14 Website, Feb

15

16 learning app, 2017

17 Supporting Implementation Catherine Baldock appointed as Manager Sept 2017 Implementation packs distributed to more than 150 interested sites Support and outreach to sites

18 process of adoption Responsibilities and requirements document Governance Continued feedback Education across health care settings Primary Secondary Ambulance services Care homes Hospices

19 Current and planned adoption Fully Adopted Coventry and Warwickshire Dec 2016 includes UHCW and GEH Acute Trust, Warwick FT, CCG s, Nursing Homes, Myton, WMAS Heart of England Jan 2017 includes HEFT, Good Hope, Solihull, 2 CCG s, WMAS Manchester Central May 2017 includes Manchester Royal, Manchester Eye Hospital, Altrincham, St Mary s and Trafford General North & Mid Hampshire Sept 2017 includes CCG s, hospices, Ambulance Service Plans to adopt include: 9 trusts and associated health care communities with explicit go live dates in other trusts planning implementation More than 70 others considering 9 have decided to hold off.

20 Feedback essential

21 challenges to date Section 6 ( the discussion section) simplified section developed and approved by lawyers, to be piloted Patient information leaflet simplified down to 1.5 pages Audit tool being developed, will be available in Jan 2018 Digital

22 - the digital challenge Ideally we would like : a universally accessible, smartphone friendly, intuitive digital solution that interfaces with primary and secondary care ( as well as ambulance crews and hospices and care homes) And can be printable so the patient can have a copy at home Which somehow links to and updates the electronic version But. The NHS is NOT digitally integrated No simple solution So. 3 stages of development:

23 - the digital challenge 1. A writable PDF (or Word Forms) document will be available early A standard template (digital archetype) for health care software engineers is being developed to integrate into other systems 3. Options are being explored for establishing a hosted service for data. - could potentially provide access to data from any EPR system or via web interface/app to any authorised user. - This step presents significant challenge - but the contained, discrete data set that represents may be a good vehicle to deliver this.

24 What s next?

25 - what s next? Resuscitation Council (UK) has agreed to support continued development, education and evaluation as part of their strategic plan Implementation Network being developed : Jan 2019 Education subgroup forming to develop further education materials including a stand-alone open-access module on the process Seminars and workshop planned London, April 2018 to share learning from early implementor sites and discuss future development

26 - what s next? is a dynamic process Developed in response to evidenced problems with DNACPR Driven by a desire to provide better care for our patients Dependent on continued engagement and feedback from those who are using it

27 feedback please Your feedback and engagement is crucial join the implementation network come to the meeting in April us or and feel free to ask questions today! Thank you