Title NHS South East Coast Do Not Attempt Cardio Pulmonary Resuscitation Principles (DNACPR) Author DNACPR working group (sub group of EOL Clinical Advisory Group) Date Principles finalised 1 st July 2010 Implementation Plan Review Date July 2013 Related legislation, guidance & policy Version Control Version 6.2 July 2010 Approved by Quality Board - Planned launch and implementation September 2010 NHS SEC Medical and Nursing directors aware and consulted with. SHA Communications Directorate supporting launch DNACPR group meeting in August to finalise launch and implementation plan following Quality Board decision. Mental capacity Act.2005 Human rights act.1998 Joint statement on decision related to cardiopulmonary resuscitation from RCN, BMA and resuscitation Council. 2007 NMC Advice statement. May 2008 GMC guide, Treatment and Care towards the end of life. May 2010 The NHS South East Coast, End of Life Care, Clinical Advisory Group overarching principles for NHS and voluntary sector organisational policies on Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) v6.2 Purpose: The purpose of the principles set out below is to give a consistent approach to the issue of DNACPR across the region which will therefore allow portability of the decisions across care settings in line with best clinical practice.
The Key Principles for DNACPR policies are that they; Apply to adults over 16 years. Apply to all care settings and be transferable from one setting to another including during transport. Must be consistent with the Decisions related to cardiopulmonary resuscitation; a joint statement from the BMA, the Resus Council & RCN Oct 2007 (Summarised in appendix 3), the GMC Guidelines, Treatment and care towards the end of life: and the NMC advice statement on Resuscitation May 2008. (appendix 4) Recognise that the DNACPR form remains valid from the date of signing unless a review date has been specified. Recognise that a review date does not have to be specified. Who can make the decision? The responsibility for decision-making and DNACPR must always rest with the most senior clinician currently in charge of the patient s care. In the majority of cases this will be the consultant or GP, although they may delegate the responsibility to another registered medical practitioner. In certain settings an experienced nurse may be the senior clinical decision maker. Examples include nurse consultants or senior clinical nurses working in palliative care with appropriate training, subject to local discussion and agreement. Nurses will undertake a training programme and competency assessment as part of an extended role. The programme and competencies will be inline with those agreed by the SHA Clinical Advisory Group. It will be for individual organisations clinical governance committees to decide upon whether they wish to train appropriate members of their nursing staff to undertake the DNACPR discussion and form completion. To enable portability of the decision and hence form from one setting to another, accountability for any clinical governance issue which might arise as a result of completion of the DNACPR form remains with the signatory s employing organisation. Wherever possible, a decision should be agreed by 2 senior members of the health care team responsible for the patients care and treatment. It is good practice to ensure the patient s GP/Consultant is informed at the earliest opportunity Recording and communicating the decision; a guide to completing the red DNACPR form. The NHS South East Coast EoLC Clinical Advisory Group has agreed that The Resuscitation Council red bordered model DNACPR form (Appendix 1) will be the preferred form for recording the decision. The red form with an ink signature will be considered the active document and will be considered the patients property as the form needs to move with the patient when transferring from one care setting to another for example form hospital to home so that Out of Hours (OOH) services and ambulance services can see the signed formed if and when necessary. The grey decision record (Appendix 2) will be the preferred method of recording the decision and can then remain in the originators notes. This form can then used to communicate the decision to other involved in the patients care and the ambulance service, GP/ OOH service. This may be by fax or other timely means. The red and grey forms may be produced in a carbonated pad, or other alternate method, however the red from will require an ink signature to be valid.
If there is a clinical electronic record system, a brief statement should be made to indicate that a DNACPR form has been completed including the date, time, reasons for the decision and those in the decision making process. Depending upon local practice, the presence of a signed DNACPR form should be recorded in alert systems such as for example the message in a bottle system. The senior clinician responsible for the patient in other words their Consultant, GP or appropriately trained Senior Nurse when completing the red form will sign in section 7. Their signature does not require any further endorsement and if no review date is specified no further signatures need be entered in this section. The red form may be signed under delegated authority by a senior medical practitioner who is not ultimately responsible for the patients care in section 6. Examples include doctors on-call in the hospital setting and visiting GP s in the OOH setting. The form completed in this way needs endorsement of the Consultant, GP or appropriately trained Senior Nurse responsibly for the care of the patient as soon as is practical. They will counter sign the form in section 7. In an in-patient setting the DNACPR form should be completed with the NHS number and hospital number, taking the hospital number to include other in-patient settings such as a hospice. Forms signed in the community will only have the NHS number. Both are equally valid. The purpose of these numbers is to facilitate governance and audit arrangements. The use of printed patients sticky labels on both the red and grey forms is acceptable. Both forms have space to provide detail or logo of the originating organisation and contact telephone number. The principles are accompanied by the document DNACPR Training Programme and Competency Assessment for Senior Nurses to guide the content of locally developed training programmes. The principles are also accompanied by a set of FAQs.
Appendix 1 DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION Name Address Date of birth Adults aged 16 years and over Organisation LOGO Telephone number Date of DNACPR order: / / NHS & Hospital numbers / DO NOT PHOTOCOPY In the event of cardiac or respiratory arrest no attempts at cardiopulmonary resuscitation (CPR) will be made. All other appropriate treatment and care will be provided. 1 Does the patient have capacity to make and communicate decisions about CPR? If YES go to box 2 If NO, are you aware of a valid advance decision refusing CPR which is relevant to the current condition? If YES go to box 6 If NO, has the patient appointed a Welfare Attorney to make decisions on their behalf? If YES they must be consulted. YES / NO YES / NO YES / NO All other decisions must be made in the patient s best interests and comply with current law. Go to box 2 2 Summary of the main clinical problems and reasons why CPR would be inappropriate, unsuccessful or not in the patient s best interests: 3 Summary of communication with patient (or Welfare Attorney). If this decision has not been discussed with the patient or Welfare Attorney state the reason why: 4 Summary of communication with patient s relatives or friends: 5 Names of members of multidisciplinary team contributing to this decision: 6 Healthcare professional completing this DNACPR order: Name Position Signature Date Time 7 Review and endorsement by most senior health professional: Signature Name Date Review date (if appropriate) Signature Name Date
Appendix 2 Name Address Date of birth DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION DECISION RECORD NHS & Hospital numbers / Adults aged 16 years and over Organisation LOGO Telephone number Date of DNACPR order: / / In the event of cardiac or respiratory arrest no attempts at cardiopulmonary resuscitation (CPR) will be made. All other appropriate treatment and care will be provided. 1 Does the patient have capacity to make and communicate decisions about CPR? If YES go to box 2 If NO, are you aware of a valid advance decision refusing CPR which is relevant to the current condition? If YES go to box 6 If NO, has the patient appointed a Welfare Attorney to make decisions on their behalf? If YES they must be consulted. YES / NO YES / NO YES / NO All other decisions must be made in the patient s best interests and comply with current law. Go to box 2 2 Summary of the main clinical problems and reasons why CPR would be inappropriate, unsuccessful or not in the patient s best interests: 3 Summary of communication with patient (or Welfare Attorney). If this decision has not been discussed with the patient or Welfare Attorney state the reason why: 4 Summary of communication with patient s relatives or friends: 5 Names of members of multidisciplinary team contributing to this decision: 6 Healthcare professional completing this DNACPR order: Name Position Signature Date Time 7 Review and endorsement by most senior health professional: Signature Name Date Signature Review date (if appropriate) Name Date Signature Name Date
Appendix 3 A summary of the Joint Statement: BMA/RCN/ UK Resus Council DNAR Guidelines (2007). This is not a substitute for reading the full statement. It is best practice for policies to: Explain that 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. In some cases it may prolong or increase suffering and subject the patient to traumatic and undignified death. In these circumstances, most patients want a natural death without unnecessary interventions that most consider to be undignified. Explain that earlier discussions with patients about their general care and treatment aims may have addressed this issue. For example, in the context of palliative care, where patients are known to have an incurable illness, discussion and explanation about the realities of attempting CPR may occur in advance of the last few days of life Explain that some patients may despite potentially distressing adverse effects, have specific reasons for wanting to try to delay death, even if this is only for a very short period of time. If such a wish is expressed, accurate information must be provided about the likelihood and length of survival that might realistically be expected, and about the potential risks and effects of attempted CPR. The patient should be invited to discuss the risks and benefits of CPR in order to reach an agreed decision on whether or not it should be attempted. Explain that where a DNACPR decision has been made on the grounds of burdens versus benefit rather than futility, 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 anesthesia, anaphylaxis or blocked tracheostomy tube. In such situations CPR would be appropriate, while the reversible cause is treated, unless the patient has specifically refused intervention in these circumstances. Explain that where a DNACPR decision has been made on the grounds of burdens versus benefit rather than futility, it may be appropriate to temporarily suspend a decision not to attempt CPR during some procedures if the procedure itself could precipitate a cardiopulmonary arrest. Some patients may wish a DNACPR decision to remain valid despite the increased risk of a cardio-respiratory arrest and the presence of potentially reversible causes; others will request that the DNACPR decision is suspended temporarily. The time at which the DNACPR decision is reinstated should also be discussed and agreed. Ensure that policies refer to not performing cardio-pulmonary resuscitation in other words, cardiac massage and artificial respiration. Patients and their carers need to be reassured that although cardio-pulmonary resuscitation will not be attempted, general care and comfort will remain a priority. Ensure policies are clear on who can make the decision about DNACPR. These include the patient, providing that they are over 18 years, have the mental capacity, have been informed about the treatment options and risks and are not unduly influenced, and the senior clinician responsible for the patients care. In the majority of cases this will be the Consultant or GP, although they may delegate the responsibility to another registered medical practitioner. In certain settings an experienced nurse may be the senior clinical decision maker. Examples include nurse consultants or senior clinical nurses working in palliative care with appropriate training. Neither patients nor relatives can demand treatment, which the health care team judges to be inappropriate.
Ensure policies explain that where a DNACPR is signed under delegated authority by a senior medical practitioner who is not ultimately responsible for the patients care for example on-call doctors in the hospital setting and visiting GP s in the OOH setting. The form completed in these circumstances requires the endorsement of the consultant, GP or appropriately trained Senior Nurse responsibly for the care of the patient as soon as is practical. Explain that an advance verbal or written decision about resuscitation by the patient must relate to specific circumstances and will only come into effect when the individual has lost the capacity to give or refuse treatment. Explain that ideally, a decision about whether to attempt to resuscitate a particular patient at the end of life is made in advance, as part of the overall care planning for that patient. As such, it should be discussed with the patient and their family along with other aspects of future care. This will be particularly important to consider for patient s whose condition may or will affect their ability to communicate at a later stage e.g. Motor Neurone Disease. Explain that in an in-patient setting when a clinical decision has been made that CPR should not be attempted, because it will not be successful, and the patient has not expressed a wish to discuss CPR, it may not be necessary or indeed not be appropriate to initiate such as discussion. Explain that where a patient is at home it will be clearly inappropriate not to discuss the DNACPR issue if the clinician is planning to leave a signed DNACPR form in the patients house. Explain that where no explicit advance decision has been made about the appropriateness or otherwise of attempting resuscitation prior to a patient suffering cardiac or respiratory arrest, and the express wishes of the patient are unknown and cannot be ascertained, there should be a presumption that health professionals will make all reasonable efforts to revive the patient. Explain that if the patient is unable to make the decision, the family should be consulted at the earliest opportunity before the Consultant, GP or appropriately trained Senior Nurse makes the decision on the patient s behalf after careful discussion with the multi-disciplinary team. Such discussion need to be undertaken by experienced staff since relatives must be reassured that they are not responsible for the decision but are key to ascertaining the patient s wishes. Explain that if the patient lacks capacity and has appointed a welfare attorney whose authority extends to making these clinical decisions, or if a court has appointed a deputy or guardian with similar authority to act on the individual s behalf, this person should be informed of the decision and the reason for it. If a second opinion is requested, this should be arranged, whenever possible. Explain that there is no ethical obligation to discuss resuscitation with those palliative care patients for whom such treatment would be futile (National Council 2002). The Consultant, GP or appropriately trained Senior Nurse is required to make a risk assessment of the burden versus benefit of the discussion tailored to each patient and to act in the patient s best interests. However, people have ethical and legal rights to be involved in decisions that relate to them. Thus, where competent patients are at foreseeable risk of cardiopulmonary arrest or have a terminal illness, there should be sensitive exploration of their wishes regarding resuscitation. This will normally arise as part of general discussions about that patient s care. The topic may be introduced by discussing the patient s deteriorating condition and inevitable imminent death rather than specifically being confined to resuscitation decisions.
Stipulate that where a decision has been made in one healthcare setting, often involving significant discussion with the patient and/or the family, it is important that this decision is respected when the patient is transferred to another setting (e.g. between hospital, home and hospice), unless the situation or circumstances have changed. The Principles for DNACPR policies have been developed to ensure consistency of approach and portability of the decision making so that it is recognised if the patient moves form one care setting to another. Orders completed outside the local area will also be respected where it is clear that they fulfil the appropriate criteria and the situation has not changed. The patient s key worker must be informed of the DNACPR order and they must hand this information over if there is a change of key worker. State that decisions about resuscitation must be reviewed where a review date has been stipulated on the DNACPR form and equally should be reviewed if there are changes in the patient s condition and wishes, for examples where changes have occurred that could not have been predicted at the time the form was originally signed. If the GP, Consultant or appropriately trained Senior Nurse signing the DNACPR form feel that it will be clinically appropriate to review the decision they must enter a review date and will therefore need to make appropriate arrangement for this review to take place.
SEC SHA DNACPR Unified Principles Frequently Asked Questions for healthcare professionals V1.4 1. What guidelines have been used in the development of the principles document? The principles have been developed to take account of the best practice joint statement by the BMA, RCN and Resuscitation Council (Nov 2007). The NMC have issued an advice statement (May 2008), recognising the joint guidance and clarifying that, senior nurses could be signatories with appropriate training. The principles also in line with the GMC guide, Treatment and care towards the end of life: good practice in decision making (May 2010). The GMC guide contains a legal annex of the key legislation for reference purposes. It is important that the principles are read and understood in the context of the Mental Capacity Act 2005. 2. Why are they referred to as principles and not policy? The aims of the principles are to get best practice adopted to include a unified way of working across South East Coast including using a standard DNACPR form that is portable and could therefore travel with the patient and would be recognised a valid form one organisation to another. This allows flexibility on policy to enable individual trusts and organisations to have operational flexibility. An example of this being that community services may wish to train nursing staff to be able to act as decision makers and therefore signatories, where as acute trusts may feel that this is not necessary due to the presence of medical staff. 3. What can be done to ensure that the ambulance service is sure which resident at the address the DNACPR relates to? The ambulance service is in the process of upgrading IT systems that will flag patients by name as well as address. 4. What can the paramedics do if they attend a patient s home where there is a valid DNACPR agreement and the carer is insisting on the patient being resuscitated? In this situation paramedics would not be expected to commence CPR if an active, signed and valid red DNACPR form is present If the form is present with the patient the paramedics would be supported by the ambulance trust in not performing CPR as the presence of the form demonstrates the patient s wishes. 5. How have care homes and patients/carers been involved with the development of the principles? The principles were developed by a sub-group of the SEC SHA EOLC clinical advisory group so that organisations across NHS South East Coast could take a common approach to the DNACPR issue, based upon the joint statement from the BMA, RCN and Resus Council UK. The principles have been informed by a body of work extending over a 10 year period which has had the benefit of numerous informal inputs including from care home and patients/carers.
6. Where does clinical judgement fit with a signed agreement? Clinicians must always act in the patient s best interests, which includes respecting advance decisions, however they also have to exercise clinical judgement. If for example the set of circumstances are beyond what could have been envisaged when the DNACPR was completed the clinicians should act appropriately, a good example would be a patient choking on a piece of food. Clinicians therefore must be able to justify their actions at all times. 7. Do the paramedics have to see the signed form rather than a copy? Yes; the active red form is not intended to be copied. If lost a new form could be issued. 8. If the GPs complete an electronic version, how can this be made available in the home? If completed electronically the form will need to be printed and given to the patient as they will require a hard copy. 9. What should the consultant/gp/nurse do if they do not feel it is in the patient's best interest to discuss DNACPR? It not always necessary to discuss a DNACPR order with a patient or their family/carers for example in a setting where end of life care is being provided. However, clinicians have to justify their actions. In an inpatient setting it may well be justified not to discuss the issue, however in a patient s home it would be difficult to envisage a situation where one would leave a form in the home where the patient may discover it with out having discussed it first. The balance of burden would be reversed in most home situations. In the home situation such discussions should be had involving carers and relatives (with the patient s consent): this would be considered not just good practice but desirable so that all involved can be clear about what to expect and, for example, which service they should call for help if needed. The DNACPR form and process are seen as key components to help facilitate a patient s wishes to die at home and avoid an inappropriate transfer to hospital at the end of life.
Appendix 6 Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) Training Programme and Competency Assessment for Senior Nurses. V.2 The Training Programme and Competency Assessment is the agreed guide to support the NHS South East Coast End of Life Care, Clinical Advisory Group overarching principles document for the NHS and voluntary sector organisational policies on Do Not Attempt Cardio-Pulmonary Resuscitation. The overarching principles are compliant with the Joint Statement on DNACPR by the BMA, RCN and Resuscitation Council, and the NMC advice statement (Appendix 4). The overarching principles make no obligation for individual organisations to train non-medical staff to undertake this role. The decision to train non-medical staff in this extended role lies with individual organisations that retain accountability for the clinical governance for DNACPR decisions that originate within their operational jurisdiction. This allows for the portability of the decision making and the completed DNACPR form. The Nursing Midwifery Council recognises that in certain cases it will be appropriate for appropriately trained Senior Nurses to fulfil this role (Appendix 4). The NHS South East Coast Training Programme and Competency Assessment enables both a uniformity and a recognised level of competence in the decision making required to complete the DNACPR form, so that a competed form is to be respected by healthcare professionals across organisational boundaries. Training Programmes Senior Nurses will be able to undertake the extended role for completing DNACPR once they have passed the competency assessment process as documented below. Since this role will only be extended to senior experienced nurses the training programmes are likely to be tailored to the identified educational needs of individual nurses or small groups of nurses within individual organisations. The aim of undertaking such a training programme is to develop the practice of experienced nurses, so that they can discuss decision making for DNACPR with patients and significant others. Senior Nurses will utilise a framework of skills and competency that reflect sound clinical knowledge and judgement. Competency Assessment and Documentation A signed off Competency Assessment should be achieved by individuals as soon as possible after completion of the training programme. It is expected that this will have occurred 3-6 months after completing training activities. The individual will have demonstrated competency at the level of an independent practitioner to an assessor/supervisor before being deemed able to practise independently. The individual is responsible for arranging time with a supervisor/assessor to undertake appropriate observation in clinical practice. The assessor/supervisor will recognise if the performance is satisfactory or not; and if any further experience is required. The competency and assessment documentation is to be retained as evidence of an individual s competency.
Competences have been developed with reference to the following documents : The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process 2004 DOH; CHS48 Communicate significant news to individuals, Skills for Health 2007; Decisions Relating to Cardiopulmonary Resuscitation model information leaflet BMA.
DNACPR TRAINING Competency Completion Meeting/observation Dates Reflection/Discussion with Assessor Signatures This confirms that reflective discussion has taken place to facilitate the completion of the competency record If not thought competent following 3 assessments, further education and support will be required Supervisor/Manager.Date Nurse Date
DNACPR COMPETENCIES SURNAME FORENAME CLINICAL SETTING ASSESSOR S POSITION A&E GP Surgery Community Care Home Hospice Hospital Consultant GP SpR/SHO CNS Nurse Consultant Lecturer Practitioner COMPETENCY OUTCOME/ EXPECTATION DATE PRACTITIONER/ ASSESSORS SIGNATURE LEGISLATION Knowledge of national and local guidance Is able to refer to national and local guidelines and policies Records and documents information clearly, concisely and accurately Demonstrates appropriate record keeping and completion of documentation Evidences awareness of keeping completed form in an appropriate place. COMPETENCY OUTCOME/ EXPECTATION DATE PRACTITIONER/ ASSESSORS SIGNATURE
PROFESSIONALISM Reflection on own practice Ability to recognise own learning needs and identify how to meet these Takes responsibility for attending appropriate training COMPETENCY OUTCOME/ EXPECTATION DATE PRACTITIONER/ ASSESSORS SIGNATURE COMMUNICATION SKILLS Communicates skilfully with the patient and/ or proxy Creates awareness of the purpose of the discussion Communicates skilfully about patient wishes and decisions Demonstrates an appropriate approach to enable ease of discussion Demonstrates the use of language which is easily understood Shows ability to use a wide range of communication skills, including open questions, clarification and summarising Responds to questions honestly and accurately and provides opportunity for questions
Allows for the expression of emotion Communicates with the multiprofessional team Demonstrates appropriate consultation with team members Shows awareness of the need to transfer decision documentation with the patient between care settings
COMPETENCY OUTCOME/ EXPECTATION DATE PRACTITIONER/ ASSESSORS SIGNATURE CLINICAL JUDGEMENT Reaches a decision regarding DNACPR with patient and/ or proxy Demonstrates review of individuals medical history to understand current situation Able to weigh and discuss the factors that influence decisions in relation to CPR based on the potential benefits and burdens. Assess the patient s capacity to make informed decision EQUALITY AND DIVERSITY Acknowledges the influence of culture, ethnicity and faith on patients and families Demonstrates understanding of different cultures, faiths and ethnicity which may effect patients decision making
SOUTH EAST COAST AMBULANCE SERVICE