Recording and promoting good decision-making The Emergency Care and Treatment Plan Dr David Pitcher Vice President Resuscitation Council (UK)
Author / co-author / contributor on this topic: National guidance: Decisions relating to cardiopulmonary resuscitation ABC of Resuscitation European Society of Cardiology elearning: Acute Cardiac Care ALS Course Manual Resuscitation Council (UK) Resuscitation Guidelines Led intervention by RC (UK) in the Court of Appeal 2014 Led development of RC (UK) model DNACPR form 2008/9 Co-chair of ETCP Working Group No financial conflicts of interest
Good decision-making Where are we starting from? Where have we got to? Where are we going?
Where are we starting from? If I wanted to get there, I wouldn t start from here
Decisions to withhold CPR Considering Discussing are challenging Recording Misunderstandings Poor decision-making are common Communication failures
Difficulties for everyone conversations about death and dying changing emphasis: from prolonging life to ensuring comfort conversations that focus on withholding treatment seen as potentially life-saving.
NCEPOD in-hospital cardiac arrest 2011 Only 22% had a recorded decision about CPR but physiological instability/warning signs in 73% Many elderly, potentially fatal chronic conditions, limited functional capacity In 196/230 expert advisors felt DNACPR decisions warranted CPR attempted in 52 with DNACPR decisions and 7 on end-of-life care pathways
Court of Appeal 2014...presumption in favour of patient involvement......anecdotal reduction in DNACPR decisions......but surely leaving someone for CPR when they may not want it is also a breach of their human rights...
October 2014 there are clear benefits in having (CPR) decisions recorded on standard forms that are recognised across geographical and organisational boundaries within the UK.
Royal Society of Medicine - October 2014 DNACPR from best evidence to best policy and practice
Emergency Care and Treatment Plan Development of a national document and process Facilitated by the RC (UK) and RCN Broad stakeholder and public/patient engagement Working group - met first February 2015
Health Select Committee March 2015 we recommend that the government review the use of DNACPR orders including whether resuscitation decisions should be considered in the context of overall treatment plans. there is a case for standardising the recording mechanisms for the NHS in England.
A new document on its own will not change behaviour, but
A new document on its own will not change behaviour, but
Some key features Promote good decision-making Encourage more conversations Identify priorities/goals of care Promote good recording Used across all care settings For individuals of all ages A change of culture
Emergency Care and Treatment Plan Record summary information and reasons for the chosen plan
Emergency Care and Treatment Plan Identify overall priorities for care and treatment
Emergency Care and Treatment Plan Record decisions about: what would be wanted if needed what would not be wanted what will not work Record details of other care-planning documents
Emergency Care and Treatment Plan Record decision whether or not to attempt CPR
Conversations about CPR More acceptable if they: occur in the broader context of a person s priorities for their care and treatment include decisions to attempt CPR
Emergency Care and Treatment Plan Ensure that decisions comply with capacity legislation Confirm when and with whom decisions have been discussed and if not, why not Signature of clinician completing the ECTP Signature of senior responsible clinician Details of emergency contacts
If a treatment will not work it should not be offered
People cannot use an ECTP to demand treatment that is not being offered Doctors do not have to seek consent to withhold treatment that is not offered (because it will not work) but using these statements in a conversation with a patient will be unhelpful
When treatment will not work involve the patient: Explain decisions and the reasons for them in a sensitive way in the context of their priorities
When treatment might work make shared decisions
When people lack capacity:
Good decision-making Each decision must be based on each individual s situation Every decision must be: free from any discrimination guided by the quality of future life that the individual would regard as acceptable
Good decision-making Recognise when a decision may be appropriate Plan ahead avoid having to decide in a crisis Inform and involve people in decisions Communicate effectively with all check understanding Document decisions, discussions and reasons
Recognising who may need an ECTP Long-term condition Admission to hospital Increasing frailty Disability Approaching the end of life ADRT or advance directive
Who should start a conversation about ECTP? The person best able to support the patient/family because they: know them well have good communication skills
Shared decisions Require: people to be well enough time to consider carefully time to discuss fully
Make explicit decisions when they are needed Don t delay a decision: because a person is not well enough to have it explained because family/representatives are not available Make/record a plan to explain/discuss/review decisions
In summary: Involve the patient make shared decisions Involve those important to the patient support Involve other members of the healthcare team The senior responsible clinician carries the ultimate responsibility for good decision-making
Where are we going? Consultation/usability Piloting Implementation 40
What will it involve? Everyone Commitment Time Perseverance
Where are we going? Better, safer care and treatment 42
Are we nearly there yet? A dynamic document and process that is responsive to feedback and continues to evolve 43