Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy 1

Policy Title: Executive Summary: Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy Cardiopulmonary resuscitation (CPR) can be attempted on any individual for whom cardiac or respiratory function ceases. However, in some people this would be inappropriate, futile or against the individual s wishes. It is therefore essential to identify patients for whom cardiopulmonary arrest would represent a terminal event in their illness and for whom CPR is inappropriate Supersedes: Version 4.0 Description of Amendment(s): 5.0 Who Makes the Decision? 7.0 Endorsement and Review of a DNACPR Order This policy will impact on: Clinical practices Financial Implications: None Policy Area: Applicable for inpatients only, i.e. patients within the Acute setting of East Cheshire NHS Trust Document Reference: Version Number: Version 5.0 Effective Date: May 2012 Issued By: Medical Director Review Date: May 2015 Author: Jackie Cornes Impact Assessment Date: April 2012 APPROVAL RECORD Committees / Group Date Consultation: Legal Services Resuscitation Committee Risk Management Group April 2012 May 2012 Engagement Officer Approved by Director: Medical Director April 2012 Received for information: Operational Communication Forum (OCF) Staff Matters May 2012 May 2012 2

Contents Page 4 1.0 Policy Statement 4 2.0 Background 4 3.0 Organisational Responsibilities 5 4.0 Application 6 5.0 Who Makes the Decision? 8 6.0 Documentation and Communication 8 7.0 Endorsement and Review of a DNACPR Order 9 8.0 Validation of a DNACPR Order 9 9.0 Other Considerations 9 10.0 Implementation and Access to this Policy 10 11.0 Measuring Performance and Audit Completion 10 12.0 DNACPR Policy Review 10 13.0 Equality and Diversity 11 References 12 Appendix 1 DNACPR Order (Red Form) 14 Appendix 2 Equality Analysis (Impact Assessment) 3

1.0 Policy Statement Cardiopulmonary resuscitation (CPR) may be attempted on any individual for whom cardiac or respiratory function ceases. Such events are inevitable as part of dying. CPR can theoretically be used on every individual prior to death. However, in some people this would be inappropriate, futile or against the individual s wishes. It is therefore essential to distinguish those patients for whom CPR would be inappropriate. 2.0 Background The factors surrounding a decision whether or not to initiate CPR involve complex clinical considerations and emotional issues. The decision for CPR of one patient may be inappropriate in a superficially similar case. In conjunction with the General Medical Council (GMC) a joint statement by the British Medical Association (BMA), the Royal College of Nursing and the Resuscitation Council (UK) was issued in October 2007. Recommended standards for recording DNAR (Do Not Attempt Resuscitation) decisions were issued in 2009 by the Resuscitation Council. The GMC also published guidelines Treatment and care towards the end of life: good practice in decision making in July 2010. The aforementioned guidelines have been used to prepare this document. This policy respects the individual s absolute right to life in accordance with the Human Rights Act (1998) and the Mental Capacity Act (2005). Copies of this policy are circulated to all wards and clinical departments within the Acute setting of East Cheshire NHS Trust. The policy is also available on the Trust s website. Within the inpatient areas information leaflets (Ref: 10172) are available to all who may wish to consult them, including patients, families and carers ( Decisions about Cardiopulmonary Resuscitation ). Further information about these issues can be obtained from the. 3.0 Organisational Responsibilities 3.1 Chief Executive Has ultimate responsibility for the implementation and monitoring of this policy. This responsibility may be delegated to an appropriate colleague, for example the Medical Director. 3.2 All Directors Directors are responsible for the implementation of this policy; the Medical Director is responsible for ratifying this policy. 3.3 The Resuscitation Committee The Resuscitation Committee is responsible for the development, consultation and approval process of this policy. The committee is also responsible for reviewing the policy to ensure that it follows the latest best practice. 3.4 The The is a full member of the Resuscitation Committee and is responsible for monitoring compliance with this policy. 4

3.5 Ward/Department/Service Managers including Consultants Managers are responsible for ensuring relevant staff have access to the policy, are trained in its implementation and are aware of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision which has been appropriately documented. 4.0 Application 4.1 For many patients the likelihood of cardio-respiratory arrest is small and no clinical decision is made in advance of such an event. If cardio-respiratory arrest does occur unexpectedly, CPR should be attempted. 4.2 In some people there is an identifiable risk of cardiac or respiratory arrest, such as an underlying incurable condition (such as advanced cancer), the history (such as recent myocardial infarction or stroke), or current clinical condition (such as severe sepsis). If there is a risk of cardiac or respiratory arrest a decision should be made in advance about the appropriateness of CPR whenever possible. 4.3 A DNACPR order (Red Form) applies only to in-patients of East Cheshire NHS Trust. The order (see appendix 1) refers solely to cardiopulmonary resuscitation; i.e. in the event of a cardiac or respiratory arrest no attempts at cardiopulmonary resuscitation will be made. All other treatment and care, where appropriate, shall not be precluded or be influenced by a DNACPR decision. 4.4 The decision is only valid during the patient s current in-patient admission and is automatically revoked on discharge from hospital. If still applicable, another DNACPR decision may be made on subsequent admissions. A new form will need to be completed for each inpatient episode. 4.5 The decision not to undertake CPR on a patient is taken following appropriate consideration of the likely clinical outcome and the patient s known wishes. The following guidelines may support a decision not for CPR: 4.5.1 Where attempting CPR would not restart the patient s heart and breathing. If the health care team is as certain as it can be that attempting CPR would not restart the patient s heart and breathing because of the patient s clinical condition, the patient cannot gain any clinical benefit from an attempt. This should be a team decision and based on clinical assessment of the patient s condition and up-to-date clinical guidelines and in the patient s best interests. 4.5.2 Where there is no benefit in restarting the patient s heart and breathing. If the patient is terminally ill and death is inevitable within a short period of time, then that person should be allowed to die naturally with full comfort and palliative measures. 4.5.3 Where the expected benefit is outweighed by the burdens of resuscitation. Where CPR may be successful in restarting the patient s heart and breathing, and thus prolong the patient s life, the benefits to be gained from the prolongation of life must be weighed against the burdens to the patient of the treatment. Again, this should be a team decision and based on clinical assessment of the patient s condition and up-to-date clinical guidelines and in the patient s best interests. 5

4.5.4 Where the patient with capacity has asked that CPR NOT be attempted. It is well established in law and ethics that adults with capacity have the right to refuse any medical treatment, even if that refusal may result in death. 4.5.5 Where a patient has a valid Advance Directive clearly refusing cardiopulmonary resuscitation. If there is any doubt about the validity of an Advance Directive, the Trust s Legal Services should be contacted as soon as possible. 4.6 If a patient or a proxy decision maker is requesting CPR in the case of a cardiorespiratory arrest, but the healthcare team believes that this would not re-start the heart and breathing, this should be explained to the patient in a sensitive way. These discussions may be difficult and where possible should be carried out by experienced senior clinicians. If the decision is not accepted, then a second opinion should be offered. 4.7 If a patient is to undergo a surgical or other invasive procedure (such as cardiac catheterisation, pacemaker insertion) then it may be appropriate to suspend a DNACPR order for the duration of the procedure and monitored recovery. Under these circumstances, the risk of precipitating an arrhythmia is increased, but the arrest is much more likely to be quickly and readily reversible. Under these circumstances please adhere to the following: Such a decision must be reviewed before the procedure with the patient or their appointed representative if they lack capacity, as part of the consent process. If a patient wishes an advance decision refusing CPR to remain valid during such a procedure and this would significantly increase the risks, and the clinician believes that it would not be safe or successful with the DNACPR order in place, it would be reasonable not to proceed. The agreed DNACPR management option must be documented and communicated to all the healthcare staff managing the patient during the procedure and recovery. 5.0 Who makes the decision? 5.1 The overall clinical responsibility for decisions about CPR, including DNACPR decisions, rests with the Consultant (or equivalent) in charge of the patient s care. When a decision needs to be made urgently, this should be by the most senior registered doctor available (Foundation Year 2 (F2) or Senior House Officer (SHO), or above) and endorsed before the end of the next day by the most senior doctor responsible for the patient s care, i.e. Consultant or doctor with equivalent responsibility. If he/she is unable to attend to sign personally, this may be delegated to a Registrar/Middle Grade doctor, who has seen and reviewed the patient and discussed the DNACPR decision with the Consultant (or equivalent) by telephone communication; directly after the telephone communication the Consultant s (or equivalent) name and position must be entered on the DNACPR Order by the Registrar/Middle Grade doctor. 5.2 Decisions should be made after discussion with the patient unless they do not wish to talk about it, lack mental capacity or have a valid advance directive. The Trust booklet on CPR should be used and given to the patient with capacity at the time of the discussion. The patient s wishes must be taken into account when making a decision. It is not appropriate to discuss resuscitation decisions with a patient who is dying unless they want this conversation. 5.3 If the patient has difficulty understanding or communicating decisions, due to sensory impairment, physical disability, lack of understanding of English or other reason, then all reasonable effort should be made to assist them in all relevant discussions. Please refer to the 6

Trust s Interpreting Policy for information. 5.4 If the patient lacks mental capacity and has an appointed health proxy (Personal Welfare Lasting Power of Attorney or a Court Appointed Deputy) then decisions about resuscitation must be discussed with them. A Welfare Attorney may be able to refuse life-sustaining treatment on behalf of the patient, if this power is included in the original Lasting Power of Attorney. Such a representative cannot insist upon CPR if it is felt by the medical team not to be in the patient s best interests. If the patient has an Independent Mental Capacity Advocate (IMCA), then there should be discussion before a decision is made. If there is disagreement then a second opinion should be obtained. Please refer to the Mental Capacity Act web page on the Trust s website for more information. NB: A referral for an IMCA must be made in the situations whereby a patient lacks capacity and does not have friends or relatives to consult; please see the Cheshire IMCA Service IMCA Referral Information and Form and the One Minute Guide: When to instruct an IMCA for more details. 5.5 If a patient decides they do not wish to have CPR attempted, this should be documented carefully in the medical record. Unless this decision is signed by the patient and the signature is witnessed, it is unlikely to meet the legal criteria for a valid advance decision. Thus some patients may prefer to make a formal, written advance decision. Please note the following: If the patient is unable to write, someone else should write it down for them. For example, a family member can write down the decision on their behalf, or a healthcare professional can record it in the person s healthcare notes. If the patient is unable to sign, they can direct someone to sign on their behalf in their presence. This must be witnessed. The witness must then sign to indicate that they have witnessed the nominated person signing the document in front of the patient making the advance decision (see the Mental Capacity Act Code of Practice, Chapter 9 What does the Act say about advance decisions to refuse treatment? ) 5.6 At the time of the discussion with the patient ensure that a record of the assessment of capacity is also documented in the medical notes. 5.7 If a patient is admitted to hospital with an advance decision refusing CPR already in place, this must be assessed for validity and applicability (see the Mental Capacity Act Code of Practice, Chapter 9 What does the Act say about advance decisions to refuse treatment? for more detail). An advance decision to refuse life-sustaining treatment must meet specific requirements: It must be put in writing. If the person is unable to write, someone else should write it down for them (see 5.5 above) The advance decision must include a clear, specific written statement from the patient making an advance decision to refuse CPR even if life is at risk. If this statement is made at a different time or in a separate document to the advance decision, the patient making the advance decision (or someone they have directed to sign) must sign it in the presence of a witness, who must also sign it. 5.8 If the patient lacks capacity a DNACPR decision should normally be discussed with the relatives, unless such discussion has previously been refused by the patient when they had capacity. However, relatives cannot give or withhold consent for the DNACPR decision. 7

5.9 Occasionally discussion with patient and/or family members may not be appropriate and in these cases the doctor should use his/her discretion. An example would be a patient who is in the last days of life, at the end of a terminal illness, and the family are aware he/she is dying. An explanation for not involving the patient, or relatives, in the decision-making process should be documented on the DNACPR Order (Red Form) e.g. patient lacks capacity and relatives not available. 5.10 The initial decision not to provide CPR should be made by the most senior doctor available in charge of the patient s care (i.e. registered doctor F2 or SHO grade, or above) after discussion with the registered nurse responsible for the patient s care and other members of the multidisciplinary team involved in the patient s care. 5.11 DNACPR orders should also be recorded for patients expected to die imminently in whom resuscitation could not be successful. If this is not done, first responders are obliged to initiate a resuscitation attempt in accordance with the Trust CPR Policy. 5.12 In cases of expected death where it has been recorded that the patient is not for resuscitation, designated nurses with the appropriate training may verify the patient s death in the absence of a doctor. 6.0 Documentation and Communication 6.1 The DNACPR order is printed on a single sheet of Red A4 paper as shown in appendix 1. The form must be completed in full, and no abbreviations are permitted. It must be dated and signed with the doctor s name and position (section 6). The guidelines for the use of the form are printed on the reverse. 6.2 The doctor recording the decision should insert this form securely into the front of the patient s medical records and document the decision in the case notes. If applicable state clearly what was discussed and agreed with the patient or health proxy. 6.3 It is the responsibility of this doctor to ensure the decision is communicated to the registered nurse responsible for the patient s care. This nurse should be involved in the decision making process and must enter their name, signature, position and the date in section 5 of the Red Form. 6.4 It is the duty of this nurse to ensure that this decision is communicated to all other relevant members of staff and documented in the nursing notes. 7.0 Endorsement and Review of a DNACPR Order 7.1 The DNACPR order must be reviewed and endorsed before the end of the next day by the most senior healthcare responsible for the patient s care, i.e. Consultant or doctor with equivalent responsibility. If he/she is unable to attend to sign personally, this may be delegated to a Registrar/Middle Grade doctor, who has seen and reviewed the patient and discussed the DNACPR decision with the Consultant (or equivalent) by telephone communication; directly after the telephone communication the Consultant s (or equivalent) name and position must be entered on the DNACPR Order by the Registrar/Middle Grade doctor. 8

7.2 A DNACPR decision should be reviewed, by the treating doctor, when clinically appropriate, e.g. following any significant change in the patient s condition. Out of hours this will be a doctor from the team responsible for that patient s care. A fixed review date is not recommended. 7.3 Whenever the decision is reviewed and the instruction is upheld, this must be recorded in the medical record by the relevant registered doctor (i.e. F2 or SHO grade, or above); name, signature and date must be entered. It is not usually necessary to discuss CPR with the patient each time the decision is reviewed. However, where a patient has previously been informed of a decision and it subsequently changes, they should be informed of the change of decision and the reason for it, where appropriate. The details of the decision and discussion should be recorded in the medical record. 7.4 If the decision is cancelled, and when the patient is discharged from hospital, the DNACPR form should be crossed through with 2 diagonal lines in black ballpoint ink and CANCELLED written clearly between them. The date, name and signature of the healthcare professional cancelling the order must also be clearly documented. The form should then be removed from the front of the patient s medical records and filed chronologically with the appropriate medical notes. If the patient remains in hospital it is vital that the nursing staff are informed of this decision immediately and details clearly recorded in the medical record. 8.0 Validation of a DNACPR Order 8.1 The decision not to resuscitate a patient is valid for the current in-patient admission only, or for the period of time documented at the last review if specified, unless the order is cancelled. 8.2 Any DNACPR orders recorded in the medical or nursing notes relating to a previous admission are no longer valid. 8.3 If the decision is appropriate for a subsequent admission, another DNACPR form must be completed, signed, dated and filed as above. 8.4 If a patient with a valid DNACPR order is transferred from/to Aston Unit (Congleton War Memorial Hospital) the order remains valid and this policy still applies. 9.0 Other Considerations 9.1 If, in the event of a cardiopulmonary arrest, the first responders are unsure of the patient s resuscitation status then a resuscitation attempt must be commenced until clarification is obtained. 9.2 This policy is under constant review and amendments may be required according to audit findings. 10.0 Implementation and Access to this Policy 10.1 All Ward/Departmental/Service Managers including Consultants will be sent a copy of this policy and must ensure that relevant staff have access to the policy and are appropriately trained in its implementation. 9

10.2 This policy will be uploaded onto the Trust s website. 11.0 Measuring Performance and Audit Completion 11.1 Please refer to the Compliance Monitoring Tool for details relating to measuring performance and audit requirements. 12.0 DNACPR Policy Review 12.1 This policy will be reviewed every 3 years by the Resuscitation Committee or more often if national guidance changes. 13.0 Equality and Diversity 13.1 This policy has been impact assessed with regards to equality and diversity and there are no areas in the policy that contravene equality and diversity guidance (see appendix 2). 10

References A Joint Statement from the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing. Resuscitation Council (UK) 2007. At http://www.resus.org.uk/pages/dnar.htm (accessed 09/04/12) Recommended standards for recording "Do not attempt resuscitation" (DNAR) decisions. Resuscitation Council (UK) 2009. At http://www.resus.org.uk/pages/dnarrstd.htm (accessed 09/04/12) Treatment and care towards the end of life: good practice in decision making. General Medical Council, London (2010). At http://www.gmc-uk.org/treatment_and_care_towards_the_end_of_life_0510_32609298.pdf (accessed 09/04/12) Department of Health. Mental Capacity Act 2005. At http://www.dh.gov.uk/en/socialcare/deliveringadultsocialcare/mentalcapacity/index.htm (accessed 09/04/12) Mental Capacity Act Code of Practice. The Stationery Office, London (2007). At http://trustnet/mca%20code%20of%20practice.pdf (accessed 09/04/12) 11

Appendix 1 Revised May 2012 DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION (DNACPR) SEE REVERSE FOR GUIDANCE NOTES TO ASSIST WITH COMPLETING THIS FORM Name Date of DNACPR order: Address Date of birth Consultant NHS or hospital number Ward 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 & communicate decisions about CPR? YES / NO If YES go to box 2 If NO to the best of your knowledge are you aware of a valid advance decision refusing YES / NO CPR which is relevant to the current condition? If YES go to box 4 (if appropriate) then complete boxes 5 and 6 If NO has the patient appointed a Welfare Attorney (as part of a lasting Power of Attorney) to make decisions on their behalf? If YES they must be consulted If NO any other persons involved in patient s welfare must be consulted if available. If no such person exists then an IMCA must be instructed. IMCA instructed? YES / NO YES / NO All 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 and identify their names. If not communicated, state the reason why: 5 Registered nurse responsible for patient s care: Name Signature Other professionals contributing to this decision (list): Position Date 6 Healthcare professional (i.e. Registered Doctor, F2/SHO or above) completing this DNACPR order: (PRINT) Name Position Signature Date Time 7 Endorsement (required before the end of the next day) by Consultant or equivalent: (PRINT) Name Position Signature Date Time Or, if after telephone discussion, endorsement is delegated to Registrar/Middle Grade Doctor by Consultant/equivalent, give details below: Consultant/equivalent: (PRINT) Name Position Registrar/Middle Grade Doctor: (PRINT) Name Position Signature Date of discussion: Time 12

Guidance notes to assist with completing this form This form should be completed legibly in black ball point ink. All sections should be completed. The patient s full name, date of birth and address should be written clearly or addressograph attached. The date of writing the order should be entered. An acceptable entry in the clinical notes would be In the event of cardiac or respiratory arrest patient is not for Cardiopulmonary Resuscitation (do not use abbreviations). This order will be regarded as INDEFINITE for this hospital admission unless it is clearly cancelled after review. The order should be reviewed when clinically appropriate - e.g. a change in the patient s condition. A fixed review date is not recommended. If after review, the DNACPR is cancelled, the form should be crossed through with 2 diagonal lines in black ball-point ink and CANCELLED written clearly between them, signed, name printed and dated by the healthcare professional responsible for cancelling the order. On discharge from hospital the order must be cancelled by the named nurse or doctor responsible for the patient s care using the instructions detailed in the bullet point above. 1. Capacity / advance decisions: Record the assessment of capacity in the clinical notes. Ensure that any advance decision is valid for the patient s current circumstances. 16 and 17-year-olds: Whilst 16 and 17-year-olds with capacity are treated as adults for the purposes of consent, parental responsibility will continue until they reach age 18. Legal advice should be sought via the Trust Legal Department in the event of disagreements on this issue between a young person of 16 or 17 and those holding parental responsibility. 2. Summary of the main clinical problems and reasons why CPR would be inappropriate, unsuccessful or not in the patient s best interests: Be as specific as possible. 3. Summary of communication with patient: Whenever possible and appropriate this decision should be discussed with the patient. State clearly what was discussed and agreed. The CPR information booklet should be given to the patient at this time. If this decision was not discussed with the patient, state the reason why this was inappropriate. 4. Summary of communication with patient s relatives or friends: If the patient does not have capacity, their relatives or friends should be consulted. However, relatives cannot give or withhold consent for the DNACPR decision. If the patient has made a Lasting Power of Attorney, appointing a Welfare Attorney to make decisions on their behalf, that person must be consulted. A Welfare Attorney may be able to refuse life-sustaining treatment on behalf of the patient, if this power is included in the original Lasting Power of Attorney. If the patient has capacity ensure that discussion with others does not breach confidentiality. State the names and relationships of relatives or friends or other representatives with whom this decision has been discussed. More detailed description of such discussion should be recorded in the clinical notes where appropriate. 5. Names of members of nursing team and other professionals contributing to this decision: State the names and positions of professionals contributing to this decision. The registered nurse responsible for patient s care is to sign and date the form at the time of the decision being made. It is the duty of this nurse to ensure that this decision is communicated to all other relevant members of staff and documented in the nursing notes. 6. Healthcare professional completing this DNACPR order: This should be the most senior healthcare professional immediately available (i.e. Registered Doctor, Foundation Year 2 (F2) or Senior House Officer (SHO) grade or above). This doctor must ensure the decision is documented in the case notes. 7. Endorsement: The decision must be endorsed before the end of the next day by the most senior healthcare professional responsible for the patient s care (i.e. Consultant or doctor with equivalent responsibility). If unable to attend to sign personally, this may be delegated to a Registrar/Middle Grade doctor, who has seen and reviewed the patient and discussed it with the Consultant or equivalent. Details requested on the form must be entered at the time the decision is being made. 13

Appendix 2 Equality Analysis (Impact assessment) What is being assessed? Name of the policy, procedure, proposal, strategy or service: Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy Details of person responsible for completing the assessment: Name: Jackie Cornes Job title: Team: Professional Practice Team State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) Cardiopulmonary resuscitation (CPR) may be attempted on any individual for whom cardiac or respiratory function ceases. Such events are inevitable as part of dying. CPR can theoretically be used on every individual prior to death. However, in some people this would be inappropriate, futile or against the individual s wishes. It is therefore essential to distinguish those patients for whom CPR would be inappropriate. The factors surrounding a decision whether or not to initiate CPR involve complex clinical considerations and emotional issues. The decision for CPR of one patient may be inappropriate in a superficially similar case. In conjunction with the General Medical Council (GMC) a joint statement by the British Medical Association (BMA), the Royal College of Nursing and the Resuscitation Council (UK) was issued in October 2007. Recommended standards for recording DNAR (Do Not Attempt Resuscitation) decisions were issued in 2009 by the Resuscitation Council. The GMC also published guidelines Treatment and care towards the end of life: good practice in decision making in July 2010. The aforementioned guidelines have been used to prepare this policy. 2. CONSIDERATION OF DATA AND RESEARCH To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document This policy will support and inform the practice of all East Cheshire NHS Trust staff who are caring for patients with a DNACPR decision. No No 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) 2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a result of this document? 3. ASSESSMENT OF IMPACT Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. 14

RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes Explain your response: The service may well look after patients from different race, if a patient or carer s first language is not English then interpretation may be required. All staff should be aware of the interpretation policy and interpretation/translation facilities. All staff should also know where to find information to enable them to adhere to cultural requirements of different faiths. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? No Explain your response: This policy applies equally regardless of gender or transgender status. DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes Explain your response: Patient s/carer s having low vision may not be able to see/read the patient information leaflet Decisions about Cardiopulmonary Resuscitation, staff therefore need to know how to access alternative communication tools and/or more appropriate leaflets, e.g. with larger print. Patients/carer s with hearing loss may require a BSL interpreter when discussing decisions relating to cardiopulmonary resuscitation. Any extra information required for patients/carer s with learning disabilities should be given accordingly after assessing their individual needs. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? No Explain your response: This policy applies equally regardless of age. LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? No Explain your response: This policy applies equally regardless of sexual orientation. RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes Explain your response: See section on RACE - staff also need to be aware of the content of drugs, e.g. porcine products not suitable for Muslim patients. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes Explain your response: All staff should be aware that it is important to inform and involve carers in the care of their loved one and offer them access to support and advice as and when required. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? No Explain your response: 15

4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? No b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? Reviewed by East Cheshire NHS Trust Resuscitation Committee. 6. APPROVAL At this point, you should forward the template to: The Trust s Equality and Diversity Lead lynbailey@nhs.net The Named Nurse for Safeguarding Children melaniebarker@nhs.net Equality and Diversity response: Safeguarding Children response: 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 8. Review Date: Date completed: 24 th April 2012 The Trust s Equality and Diversity Lead: The Named Nurse for Safeguarding Children:.. 16