Do Not Attempt Resuscitation Policy PROV 27 March 2009 1
Document Management Title of document Do Not Attempt Resuscitation Policy Type of document Policy PROV 27 Description To ensure that do not resuscitate decisions are not subject to misinterpretation. To ensure that clear and standardised documentation and communication of such decisions takes place Target audience All staff who have contact with patients Author Department Directorate Siân Roberts Professional Practice and Development Provider Services Approved by Clinical Governance and Effectiveness Committee Date of approval 27 March 2009 Version Number 1 Next review date March 2011 Related documents Superseded documents Resuscitation Policy, 2009, NHS Northamptonshire (Provider Services) Resuscitation Policy, 2007, Northamptonshire Teaching PCT Internal distribution External distribution Availability All staff None All ratified policies, strategies, procedures and protocols are published on the Trust Intranet and Public Website. Contact details (of main contact for this document) Name: Siân Roberts Address: York House, Isebrook Hospital, Wellingborough E-mail sian.roberts@northants.nhs.uk 2
Do Not Attempt Resuscitation Policy Contents Formatted: English (U.K.) 1 INTRODUCTION 4 2 BACKGROUND 4 3 AIM OF POLICY 4 4 EQUALITY AND DIVERSITY 5 5 RESPONSIBILITIES 5 5.1 Chief Executive Designate and Provider Services Board 5 5.2 Service Managers/Clinical Leads 5 5.3 Staff employed by NHS Northamptonshire (Provider Services) 5 6 PRINCIPLES 5 7 ADVANCE DECISIONS (PREVIOUSLY KNOWN AS LIVING WILLS /ADVANCE DIRECTIVES) 7 8 DOCUMENTATION 7 9 REVIEWING THE DECISION 8 10 CANCELLATION OF A DNAR ORDER 8 11 DNAR DECISIONS AND PATIENT TRANSFERS 8 12 WITHHOLDING CARDIO-PULMONARY RESUSCITATION FROM INFANTS, CHILDREN AND YOUNG ADULTS 9 13 TRAINING 9 14 NHS NORTHAMPTONSHIRE (PROVIDER SERVICES) REVIEW AND MONITORING 9 15 REFERENCES 9 Appendix 1 Do not attempt resuscitation form Appendix 2 Impact assessment 3
1 INTRODUCTION 1.1 Cardiopulmonary resuscitation (CPR) is defined as the provision of basic and advanced life support delivered to a patient in a state of either respiratory arrest or cardiopulmonary arrest. Cardiopulmonary resuscitation is indicated for patients who are unconscious, not breathing and who are exhibiting no signs of circulation (The 2007 Resuscitation Guidelines for Use in the United Kingdom, Resuscitation Council) 1.2 It is essential to identify patients for whom cardiopulmonary arrest represents a terminal event in their illness and in whom attempted cardiopulmonary resuscitation would be futile. 1.3 In establishing a Do Not Attempt Resuscitation (DNAR) policy it is important that this is respected by all professionals in primary care, professionals in hospitals and hospice settings, and also ambulance personnel for transfer between places of health care provision including patient s homes. 1.4 The patient s right to refuse CPR must be respected. It may be against the clearly stated wishes of the patient to prolong what the patient sees as a poor quality of life by attempting cardiopulmonary resuscitations (CPR) 1.5 This policy relates only to the actions of CPR and not to the withdrawal of or withholding of any other treatment eg antibiotic therapy, artificial nutrition etc 1.6 This policy should be used in conjunction with NHS Northamptonshire (Provider Services) Resuscitation Policy 2 BACKGROUND 2.1 Adults survival rates on leaving hospital following CPR are in the range of 5-20% and it is well documented that patients do well if they have: Early access to emergency services/ resuscitation team Early basic life support Early advanced life support 2.2 Certain groups of patients have a very poor chance of survival (less than 1-2%) eg those with severe infections, prolonged low blood pressure, severe cardiac/renal failure or disseminated malignancy. 2.3 For children as with adults the chances of survival to leave hospital following cardiac arrest are poor, but there are some important differences in that a primary respiratory arrest, promptly treated, has a more favourable survival outcome of 70%. However, in out of hospital arrests, child survival is still less than 10%. Unlike adults, most of children who survive to leave hospital have several neurological deficits. 3 AIM OF POLICY 3.1 To ensure that do not resuscitate decisions are not subject to misinterpretation. 4
3.2 To ensure that clear and standardised documentation and communication of such decisions takes place 3.3 CPR should not be delivered where it has been identified that: CPR is not likely to restart the patients heart and breathing CPR is not in accord with the sustained wishes of the patient who is mentally competent and has capacity There is a valid and applicable advanced decision to refuse life sustaining treatment There is a previously completed, valid and applicable DNAR order 4 EQUALITY AND DIVERSITY 4.1 NHS Northamptonshire (Provider Services) recognises the diversity of the local community and those in its employment; and aims to provide a safe environment free from discrimination and a place where all individuals are treated fairly, with dignity and appropriately to their need. NHS Northamptonshire (Provider Services) recognises that equality impacts on all aspects of its day-to-day operations and has produced an Impact Assessment Framework for all its policies. 4.2 This policy has been assessed against this framework and the results presented in Appendix 2. 5. RESPONSIBILITIES 5.1 Chief Executive (Designate) and Provider Services Board The Chief Executive (Designate) and Provider Services Board are accountable for ensuring the implementation of the Do Not Attempt Resuscitation Policy within NHS Northamptonshire (Provider Services), this function is delegated to Service Managers and Clinical Leads. 5.2 Service Managers and Clinical Leads Service managers and clinical leads must ensure that all staff are aware and adhere to this policy and are also responsible for ensuring that do not resuscitate orders are audited. 5.3 Staff employed by the NHS Northamptonshire (Provider Services) All staff who may be involved in resuscitation decisions or events have a responsibility to understand and implement this policy. Any deviations should be reported on an incident form as outlined in the Trust Incident and Near Miss policy. 6 PRINCIPLES 6.1 There should be a presumption in favour of resuscitation and resuscitation should be undertaken unless a DNAR decision has been made and recorded as outlined in this policy. Age is not a bar to resuscitation and the PCT absolutely prohibits discrimination on the grounds of age alone in a DNAR decision. Any doubt should be resolved by taking reasonable steps to preserve life. 5
6.2 The Chief Medical Officer has made it clear that responsibility for decisions about resuscitation lies with the consultant or general practitioner (GP) in charge of the patient s care. Where care is shared between a hospital and general practice, the doctors should discuss with each other and agree who should take responsibility for recording the decision and conveying it to those who need to know, both in primary and secondary care, including locum staff and GP deputising services.. 6.3 CPR should not be delivered where it has been identified that: CPR is not likely to restart the patients heart and breathing CPR is not in accord with the sustained wishes of the patient who is mentally competent and has capacity There is a valid and applicable advanced decision to refuse life sustaining treatment There is a previously completed, valid and applicable DNAR order 6.4 All patients should be assessed on an individual basis and any decision made for DNAR must be in the best interest of the patients and should be discussed with the patient however there is no ethical obligation to discuss CPR with those palliative care patients for whom such treatment would be futile. A leaflet, Decisions about Cardiopulmonary Resuscitation (April 2008), produced by the Resuscitation Council can be used to help the discussion. A link to this leaflet is given below: www.resus.org.uk/pages/deccprmd.pdf 6.5 In order for this to happen with non-english speaking groups of the population and other minority ethnic populations, appropriate interpretation services must be provided. Healthcare professionals who do not use competent interpreters will be likely to breach the Human Rights Act (Great Britain, 1998) that prohibits discrimination in meeting the obligations of a non- English speaking patient s right to life. 6.6 In certain circumstances, discussion with the patient may be considered inappropriate: If resuscitation, following assessment, is judged to be futile It is considered that the discussion would be so distressing to the patient that it would be detrimental to their well being The patient has indicated that they do not wish to discuss the matter The patient has been assessed as lacking capacity as outlined in the Mental Capacity Act 2005 6.7 The application of a DNAR means that if a patient suffers a cardiac and/or respiratory arrest, the emergency services will not be called and neither basic nor advanced cardio pulmonary resuscitation will be given. 6.8 DNAR orders apply solely to the application of CPR or the management of respiratory arrest. Other forms of a patient s management and/or treatment are not precluded and must not be influenced by a DNAR order. 6.9 There must an identified need to consider DNAR. It is appropriate to consider a DNAR decision in the following circumstances. 6
Where a patient is in the terminal phase of illness or for whom the burdens of the treatment clearly outweigh the benefits. Where CPR is not in accord with the recorded, sustained wishes of the patient who is deemed mentally competent to make the decision Where CPR is not in accord with a valid advanced decision to refuse life sustaining treatment 6.10 Responsibility for the DNAR order lies with the senior doctor on duty. It is their responsibility to enter the DNAR decision in the patient s medical records including the rationale for the decision and those who are involved. 7 ADVANCE DECISIONS (PREVIOUSLY KNOWN AS LIVING WILLS/ADVANCE DIRECTIVES 7.1 The Mental Capacity Act sets out formalities for advance decisions that refuse lifesustaining treatment. Providing care or treatment for people who have made advance decisions is a complex area and it is advisable to refer to the Mental Capacity Act Code of Practice for more detailed guidance. 7.2 Advance decisions to refuse life-sustaining treatment -. An advance decision to refuse life-sustaining treatment must fulfill the following requirements: Be written by a person over 18 years old with mental capacity It must be in writing, which includes being written on the person s behalf or recorded in their medical notes It must be signed by the maker in the presence of a witness who must also sign the document. It can also be signed on the maker s behalf at their direction if they are unable to sign it for themselves It must be verified by a specific statement made by the maker, either included in the document or a separate statement that says that the advance decision is to apply to the specified treatment even if life is at risk. If there is a separate statement this must also be signed and witnessed 7.3 A doctor might not act on an advance decision if: The person has done anything clearly inconsistent with the advance decision which affects its validity (for example, a change in religious faith) The current circumstances would not have been anticipated by the person and would have affected their decision (for example, a recent development in treatment that radically changes the outlook for their particular condition) It isn t clear about what should happen A dispute about the validity of an advanced decision and the case has been referred to the court 8 DOCUMENTATION 8.1 The decision to withhold CPR must be recorded in the patient s notes and on the Do Not Attempt Resuscitation Form (see Appendix 1). The completed Do Not Attempt Resuscitation form should be filed in the front of the patients accompanying medical notes/ patient care record. 7
8.2 Reasons for the decision and the persons involved in making the decision should be recorded in the patient s medical notes/ patient care record and on the Do Not Attempt Resuscitation form. The decision must be communicated to all those involved in any aspect of the patient s care including dentists, podiatrists etc. 8.3 Do Not Attempt Resuscitation decisions should be included as part of the communication during every handover in the inpatient areas. 8.4 Documentation regarding the discussions with the patient and relatives relating to the decision to withhold resuscitation must be included in the patient s records, as should any reason for not involving the patient in the decision making process. 8.5 Documentation and effective communication will ensure that other services are made aware of the DNAR order should the patient visit other areas eg for investigation. Ambulance staff involved in transfers must be made aware of the order. 9 REVIEWING THE DECISION 9.1 Decisions about resuscitation must be reviewed regularly and in the light of changes in the patient s condition and wishes. The frequency of review should be determined by the senior doctor on duty or consultant in charge of the patient s care and will be influenced by the patient s diagnosis, potential for improvement and response to treatment. 10 CANCELLATION OF A DNAR ORDER 10.1 If a DNAR order is no longer applicable the cancellation part of the Do Not Attempt Resuscitation form must be completed (see Appendix 1), signed and dated by the senior doctor on duty or consultant. It should also be clearly documented in the front of the patients accompanying medical notes and patient care record. 11 DNAR DECISIONS AND PATIENT TRANSFERS 11.1 When a patient is transferred to the PCT from another hospital with a DNAR order, it is the responsibility of the senior doctor on duty or consultant in charge to reassess the order and decide based on the information they have at that time if a DNAR order should be in place or not. The DNAR decision should stand until this assessment has taken place. 11.2 When a patient is transferred into primary care with a DNAR order, the order should be reviewed by the GP and the decision communicated to all those involved in the patient s care. The DNAR decision should stand until this assessment has taken place. 11.3 When transferring a patient the DNAR status form should remain filed in the accompanying medical notes/ patient care record. On no account should the DNAR status forms be photocopied. 8
12 WITHHOLDING CARDIO-PULMONARY RESUSCITATION FROM INFANTS, CHILDREN AND YOUNG ADULTS 12.1 The procedure drawn up by the children s service should be followed 13 TRAINING 13.1 It is the responsibility of service managers to identify training requirements in relation to implementing this policy 13.2 Individual training requirements should be discussed as part of the Individual Performance Development Review (IPDR) process and any identified training needs to be clearly indicated within the Personal Development Plan (PDP) so that it can inform service and PCT training plans 14 NHS NORTHAMPTONSHIRE (PROVIDER SERVICES) REVIEW AND MONITORING 14.1 It is expected that areas will undertake an annual audit to ensure that all DNAR decisions are fully documented as according to the policy and the PCT audit calendar. 14.2 An audit of all resuscitation events should be carried out to ensure that they are appropriate and adhere to the DNAR policy. 14.3 A review of the contents of this policy will take place two years from the date of approval. An earlier review may be warranted if one or more of the following occurs: as a result of regulatory/statutory changes or developments due to the results/effects of critical incidents or any other relevant or compelling reason 15 REFERENCES MacKay - Jones, K. and Walker, M. (1998) Pocket Guide to Teaching for Medical Instructors. BMJ Books. London Mental Capacity Act 2005 Department of Health National Health Service Litigation Authority (2007) NHSLA Risk Management Standards for Acute Trusts Resuscitation Policy. Health Services Circular (HSC) 2000/028. London. Department of Health Resuscitation Council (UK) (2001) Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. http://www.resus.org.uk/pages/dnar.htm Resuscitation Council (UK) (2004) Cardiopulmonary Resuscitation - Standards for Clinical Practice and Training. A Joint Statement from the Royal 9
College of Anaesthetists, the Royal College of Physicians of London, the Intensive Care Society and the Resuscitation Council (UK). London. Resuscitation Council (UK) Resuscitation Council (UK) (2005) Resuscitation Guidelines 2005. http://www.resus.org.uk/pages/guide.htm [online] Resuscitation Council UK (2001) CPR Guidance for clinical practice and training in Primary Care. London: Resuscitation Council RCN/BMA Joint Statement (2001) CPR www.bma.org.uk London: BMA Ethics Dept British Medical Association, Royal College of Paediatrics and Child Health (1997) the Resuscitation Council (UK) and the Royal College of Nursing (2001) Joint Working Party between the National Council for Hospice and Specialist Palliative Care Services and the Ethics Committee of the Association for Palliative Medicine of Great Britain and Ireland. Ethical decision-making in palliative care: cardiopulmonary resuscitation (CPR) for people who are terminally ill. London: National Council for Hospice and Palliative Care Services, August 1997 (available at the Council s website: www.hospitce-spc-council.org.uk Human Rights Act (1998) Right to life 10
Appendix 1 Do Not Attempt Resuscitation Form Patient Label Comment [N1]: Resuscitation Status (please state Yes or No) Is this patient for active resuscitation? Date decision made: --/--/-- If NO please give the reason: The patient s condition indicates that resuscitation is unlikely to be successful or effective Resuscitation is not in accord with the recorded, sustained wished of the patient Communication (Please state Yes or No) Discussed with patient If no give reason:. Discussed with Next of Kin If no give reason. Doctor s Name Doctor s Signature Date and time of signing Review dates: Doctor s signature --/--/-- DNAR remains DNAR cancelled.. --/--/-- DNAR remains DNAR cancelled.. --/--/-- DNAR remains DNAR cancelled.. --/--/-- DNAR remains DNAR cancelled.. 11
Appendix 2 Policy Impact Assessment Screening Tool Name of Directorate: Provider Services Date of Assessment: 13 March 2009 Policy being assessed Do not attempt resuscitation policy Assessment Carried out by: Siân Roberts Policy Title Who is affected Statutory requirements Full Assessment Needed Yes / No Priority High / Medium / Low Do not attempt resuscitation policy All PCT staff, clinical and non clinical Human Rights Act Standards for Better Health C1a NHSLA standard 4 Resuscitation Council (UK) Guidelines 2005 The Mental Capacity Act (2005) No Low 12
Appendix 2 Policy Impact Assessment Full Assessment Tool Name of Directorate: Provider Services Date of Assessment: 13 March 2009 Policy being assessed: Do not attempt resuscitation policy Assessment Carried out by: Siân Roberts 1. What consultation process will be undertaken? 2. Where will records of this consultation be kept? 1. What existing monitoring arrangements are in place? 2. Are these sufficient? 3. Are any additional arrangements required 1. How will the results of the assessment be published? Senior Clinicians and managers within Provider Services, nationally the resuscitation council (UK) has considered equality issues in the development of the National Resuscitation Guidelines and particularly in their supporting document Decisions Related to Cardiopulmonary Resuscitation. The Mental Capacity Act provides clarity on the ways people may set down their wishes with the fundamental principle that all patients have capacity. It considers how patients without capacity should be treated. Provider Services Incident reporting, complaints, audit calendar No Monitoring of inappropriate resuscitation. Through the minutes of Provider Services Clinical Governance and Effectiveness Group which is held 2 monthly 13
Policy aims and outcomes To ensure that do not resuscitate decisions are not subject to misinterpretation. To ensure that clear and standardised documentation and communication of such decisions takes place CPR should not be delivered where it has been identified that: CPR is not likely to restart the patients heart and breathing CPR is not in accord with the sustained wishes of the patient who is mentally competent and has capacity There is a valid and applicable advanced decision to refuse life sustaining treatment There is a previously completed, valid and applicable DNAR order Evidence for assessment Incidents Complaints Audit around DNAR forms Number of inappropriate resuscitations Difference in Outcomes Ensure that policy is treating everyone equally regardless of; Age/Gender Mental Health Needs/Disabilities Race, Ethnicity, Religion, Language or Culture Assessing Impact The policy should be neutral in its equality impacts, with all patients treated fairly and in accordance with their human rights as established by the Human Rights Act 1998, and the Trusts statutory duties to promote race, disability and gender equality. These rights are reflected in the policy. Information for patients and relatives is written, therefore would disadvantage visually impaired, people with an lower than average reading age or people whose first language is not English Proposed action To source information, leaflets and advice that are available in alternative formats and languages and ensure staff are aware of where to obtain them. Audit of DNAR forms and resuscitation events to ensure staff complying with policy 14