Anthony Freestone Head of Resuscitation August 2014
The Team Anthony Freestone Heather Jordan Emma Gregson Lucy Ansell Samantha Salisbury Administrator/PA Dr. Allan Monks Head of Resuscitation Clinical Resuscitation Officer Assistant Resuscitation Officer Assistant Resuscitation Officer Resuscitation Medical Lead
Teams 2222 2222 2222 2222 2222 2222 2222 2222 4444 (9)999 Adult cardiac arrest Adult medical emergency Paediatric cardiac arrest Major Haemorrhage Team Fast bleep, Trauma team, Mobile team Neonatal emergency Antenatal emergency/cardiac arrest Postnatal emergency/cardiac arrest Major incident Paramedics
Adult Cardiac Arrest Team 2222 ST 3+ in Medicine F2 F1 Duty Resuscitation Officer CCOS/ART ALS ALS ILS ALS/Airway ALS Resident ICU Anaesthetist 2222 (2 nd Responder)
An Issue of life or death...
A decision as to how to pass the closing days and moments of one s life and how one manages one s death touches in the most immediate and obvious way a patients personal autonomy, integrity, dignity and quality of life.
Compliance & Monitoring
COMPLIANCE The DNACPR forms you consider and place on your patients are MONITORED Online DNACPR package for ALL Consultants and Senior Doctors Incomplete/ non-compliant forms are escalated to Clinical Supervisors, Medical Education for Doctors in training, Medical Lead for Resuscitation who may escalate to the Divisional or Medical Directors. An action plan will be developed with the individual to prevent re-occurrence DNACPR is part of the NHSLA monitoring process DNACPR is also part of the Medical Care Indicators
Communication Communication is so important when a DNACPR is activated You have a legal duty to discuss DNACPR decisions with patients and their Family or carers, unless to do so would cause the patient physical or psychological harm (this is more than just causing distress). Failure to do so will be a breach of Article 8 of the European Convention of Human Rights (ECHR) Involve relevant authorities if the patient is unable to communicate such as Independent Mental Capacity Advocate (IMCA) Involve the Lasting Power of Attorney (LPA) health and welfare if one is appointed...
Communication Any communication that has taken place must be documented in patient notes, stating where the conversation took place, who was involved and what was said. Failure to do so will be a Breach of Article 8 of the ECHR and could be a matter of Professional Misconduct. This would mean the Trust would be acting unlawfully and may be subject to potential regulatory censure and/or a claim for damages.
Who s Responsible for making the order... The Hospital Consultant in charge of the Patient s care Or the Patient s Personal General Practitioner (GP) if the Patient is not in hospital Other senior doctors (ST3+) only in the hospital or community may place the order on behalf of the Consultant or GP The form however, must have a Consultant or the GP authorise and endorse within 48 hours Only at this time should the form be separated and sent to the relevant departments...
Who s Responsible for making the order... Clinicians MUST: Discuss DNACPR issues with patients before making a final decision Inform the patient of the final decision and consider offering a second opinion (However, there is no obligation under Article 8 to offer a second opinion) If the patient agrees involve or inform family members If the patient lacks capacity then consult a family member or other people concerned with the patients welfare, if there is nobody - consider IMCA appointment Record discussions and decisions in the clinical records Fully complete a DNACPR form (VS932) Make sure you are aware of the Trusts policy on DNACPR (Corp/Proc/003) Consider carefully how patients/families are involved in all decisions about treatment - especially those about potentially life saving treatment
FRONT OF THE FORM Legal requirement for completion to prevent litigation (Article 8, ECHR)
COMPLETION OF THE FORM SECTION 1 The patients condition indicates that CPR would not be successful because... Because... Means: you must enter dialog in this area to substantiate your reasons for the order
Inappropriate Terminology As you are aware Trusts up and down the country have been litigated for incorrect terminology. Unacceptable terms that have been previously used Smoker Drinker Down syndrome Elderly Unconscious Amputee Deaf Registered blind Psoriasis
COMPLETION OF THE FORM SECTION 2 Summary of Discussion must be placed on each question asked to the physician making the order identifying either YES or NO... Means: you must enter dialog in this area to substantiate your reasons if the form HAS/NOT been communicated For LPA - if one is not appointed PLEASE STATE
COMPLETION OF THE FORM SECTION 3 Doctor making the order Write Clearly Identify your grade Document your GMC Number Date and Time the order Document your contact details
COMPLETION OF THE FORM SECTION 4 Consultant Endorsement The Parenting Consultant MUST be made aware at the earliest opportunity The form MUST be endorsed within 48 hours of completing the form The Consultant is required to document their GMC number Date and time the Endorsement
COMPLETION OF THE FORM SECTION 5 NWAS Involvement The form MUST be reviewed 48 hours prior to discharge or transfer The form should be either FAXED or Emailed to NWAS to ensure the order is upheld on transfer It must be documented which method has been selected when NWAS was contacted
COMPLETION OF THE FORM SECTION 6 Review & Transfer The form MUST be reviewed 48 hours prior to discharge or transfer and endorsed to confirm this Instructions MUST be articulated to the transfer team regarding deterioration or death on transfer Flowcharts MUST be followed
BACK OF THE FORM
HOSPITAL/HOSPICE FLOW CHART
COMMUNITY FLOW CHART
Can a DNACPR order be revoked... Of course the form can be revoked... The form is reviewed at every Medical Senior Ward Round or within the first 7 days post discharge with the GP (then this remains indefinite) The Consultant or GP can remove this order at anytime if the patient condition improves
Who s Informed... THE PATIENT/LPA/IMCA Patient s own Consultant or GP Family with the Patients consent Hospital Health Care Professionals involved in the care District Nurses, Trinity Hospice CNS & relevant Health Care Providers Care home/nursing home staff Social Services Out of hours service providers North West Ambulance Service
Due to community integration you will see more acute admissions with an already active DNACPR order in place To support End of Life Care and allow a natural dignified death we must remember to support the DNACPR process AND A new DNACPR order completed for that admission Ensure DNACPR orders are reviewed
Thank you for listening... Any Questions