DNACPR The new form

1. DNACPRThe new form Dr Jeena Ackroyd Consultant in Palliative Medicine Calderdale & Huddersfield NHS Foundation Trust

3. Success rates of CPR When would CPR be futile? Who makes the decision? When do we need to discuss ? The new DNACPR form Outline

4. What is the professional responsibility to provide CPR? • Our duty is to offer treatments which we believe are likely to yield more benefit than harm or risk. • No difference in principle from providing any other treatment. • CPR means just CPR and does not mean other appropriate treatment is withheld, eg antibiotics or fluids

5. How successful is CPR ? • Cardio respiratory arrest in hospital • Chance of surviving to discharge 15 % • Out of hospital arrest • Survival rate 5% • What about co-morbidities ? • What about cancer ?

6. Determinants of survival after In-hospital cardiopulmonaryresuscitation Retrospective 274 patients receiving CPR Categories in which no patient survived to discharge. Cancer with metastases Pneumonia Creatinine > 150umol/l Shock PO2 < 6 Kpa S O’Keefe et al (1991)– Quarterly Journal of Medicine

7. Pre-arrest Morbidity Index (PAM) Clinical characteristic PAM Index Malignancy Metastatic 10 Localised 3 Sepsis 5 Dependent functional status 5 Pneumonia 3 Creatinine > 130 umol/l 3 Age > 70 2 Acute MI -2

8. Patients likely to benefit from CPR • Good functional status • Early disease stage • Normal renal function • Absence of hypotension • Absence of pneumonia • Remediable cause eg. MI

9. Patients with advanced progressive disease : • CPR unlikely to be successful • Burdens outweigh the benefits • We know when CPR would be successful or not – when should we discuss it ?

10. IF CPR IS FUTILE No ethical obligation to discuss CPR with patients for whom such treatment is judged to be futile. Patients / carers do not have the right to demand medically futile treatments Informed in decision-making Preferable to emphasise end-of-life care in general when an expected part of the dying process

11. If CPR is a viable treatment option Offer opportunity to discuss with patient • Person with capacity can refuse it • person lacks capacity • decision rests with the healthcare team • Family and carers have a role in informing a healthcare team decision (especially if they have Lasting powers of attorney ) • BUT they should not be asked to make the decision

12. New DNACPR form :

13. Current Problems • All care settings including ambulance service have their own documentation to record DNACPR decisions. • Some patients are having CPR attempted inappropriately and as a result death is undignified and traumatic. • Patients’ wishes and preferences are not always clarified and respected (advance decisions to refuse treatment). • Dying patients are being transferred back to hospital when their preferred place of death is home.

14. Yorkshire & Humber SHA • The Yorkshire & Humber Regional DNACPR working group approved the new DNACPR form for use within the 12 participating PCT regions. • Form will be valid within all healthcare settings and during transfer between these settings. • Implementation date for Calderdale & Kirklees: 1st February 2011.

15. Aims of new form The DNACPR process seeks to address two particular scenarios: People dying from advanced progressive disease for whom CPR is not a viable treatment option. People with life-limiting illnesses for whom CPR may still be a viable treatment option. These people may wish to refuse CPR in the future and this is called an Advance Decision to Refuse Treatment (ADRT) and forms a small part of Advance Care Planning (ACP).

16. Policy objectives • Avoid inappropriate CPR attempts and allow natural death by making best practice decisions. • Ensure patients, relevant others and staff understand the decision-making process. • Clarify that patients and relevant others will not be asked to decide about CPR when it is not a treatment option. • Encourage and facilitate good communication with patients and relevant others. • Ensure that a DNACPR decision is communicated to all relevant healthcare professionals.

17. Documentation • ONE single form to record DNACPR decisions which is transferable across all care settings (hospital, hospice, home, care home and ambulance). • The original form is the patient’s property and follows them but copies may be made and kept in relevant hospital or community notes. • Patients may be moved between care settings with valid completed forms. • Regular review is recommended particularly on transfer of medical responsibility.

19. The process • Senior Doctor signs the DNACPR form (local policy may allow other key healthcare professionals to do so ) • In community important that family and informal carers are aware of a DNACPR decision • Form needs to be kept with the patient • Decision must be communicated to other key professionals

20. Regional Patient Information Leaflet

21. Decisions relating to cardio-respiratory resuscitation. A joint statement from the BMA, resuscitation Council, (UK) RCN (2007 ) Mental Capacity Act (2005) Treatment and care towards the end of life:good practice in decision-making (GMC,2010) National Guidance

22. Audit • Y & H SHA successfully secured Regional Innovation Fund (RIF) monies to support project Evaluation: • Demonstrate an improvement in patient experience including the documentation of decisions • Local audit directed by SHA requirements to evidence above

23. CPR DISCUSSIONS Situations when it’s OK not to discuss CPR with the patient • CPR futile • Patient states he/she doesn’t want to talk about future care • MDT believes the patient may be excessively distressed by discussion • Patient has clearly expressed a wish in the past • Patient lacks capacity • For this decision at this time

24. CPR DISCUSSIONS • When does the family get to decide? • Views always taken into account • Not their responsibility • Legal responsibility when • they have been given Lasting Power of Attorney (under MCA), • Acting in patient’s best interests • the patient lacks capacity to make that decision at that time

25. CPR DISCUSSIONS Discussion recommended prior to documentation: • When illness trajectory is uncertain. • In response to a patient or carer request or question about CPR. • When the patient has made it clear that they wish to be informed of all health care decisions.

26. CPR • Decisions • Not for CPR if futile • Otherwise – pt’s decision • Unless lacks capacity  ADRT, Lasting Power of Attorney • Discussions • Aim to explain if CPR futile • Need to discuss if not futile • Documentation • New form • Up-to- date

27. The Challenge !

28. Yorkshire Post : May 2010 • Anger after doctors put 'Do Not Resuscitate' note on records • A daughter has told of her "outrage" after discovering doctors treating her late mother did not plan to resuscitate her if she collapsed.

29. Do not resuscitate BMJ 2001;323:58 ( 7 July )

30. Any Questions ?

31. DVD