Outline Success rates of CPR When would CPR be futile? Who makes the decision? When do we need to discuss ? The new DNACPR form
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
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 ?
Determinants of survival after In-hospital cardiopulmonary resuscitation 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
Pre-arrest Morbidity Index (PAM) Clinical characteristicPAM Index Malignancy Metastatic10 Localised 3 Sepsis 5 Dependent functional status 5 Pneumonia 3 Creatinine > 130 umol/l 3 Age > 70 2 Acute MI-2
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
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 ?
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
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
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.
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: 1 st February 2011.
Aims of new form The DNACPR process seeks to address two particular scenarios: 1.People dying from advanced progressive disease for whom CPR is not a viable treatment option. 2.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).
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.
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.
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
National Guidance 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)
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
CPR DISCUSSIONS Situations when it’s OK not to discuss CPR with the patient 1.CPR futile Patient states he/she doesn’t want to talk about future care MDT believes the patient may be excessively distressed by discussion 2.Patient has clearly expressed a wish in the past 3.Patient lacks capacity For this decision at this time
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
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.
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
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.