Presentation on theme: "Consultant in Palliative Medicine Calderdale & Huddersfield NHS"— Presentation transcript:
1Consultant in Palliative Medicine Calderdale & Huddersfield NHS DNACPR The new formDr Jeena AckroydConsultant in Palliative MedicineCalderdale & Huddersfield NHSFoundation Trust
2There has been a lot of discussion about the decision making and documention on CPR and this can often be difficultIt is important to know when to and when not to offer resuscitaion
3Outline Success rates of CPR When would CPR be futile? Who makes the decision?When do we need to discuss ?The new DNACPR formPresumption in favour of CPRDo not attempt CPR if it will not restart the heart/breathingDiscussion about CPR with patients is not always necessaryCPR is "futile" when it offers the patient no clinical benefit. When CPR offers no benefit,
4What 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 fluidsyou as a physician are ethically justified in withholding resuscitation. Clearly it is important to define what it means to "be of benefit." The distinction between merely providing measurable effects (e.g. normalizing the serum potassium) and providing benefits is helpful in this deliberation.
5How successful is CPR ? Cardio respiratory arrest in hospital Chance of surviving to discharge 15 %Out of hospital arrestSurvival rate 5%What about co-morbidities ?What about cancer ?Attempting CPR carries a high risk of significant risk of adverse effects and is often traumatic meaning that death occurs in a manner that the patient and people close to the patient would not have wished
6Retrospective 274 patients receiving CPR Determinants of survival after In-hospital cardiopulmonary resuscitationRetrospective 274 patients receiving CPRCategories in which no patient survived to discharge.Cancer with metastasesPneumoniaCreatinine > 150umol/lShockPO2 < 6 Kpa41 patients with cancer37 with pneumonia25 patients left hospital aliveSurvival to discharge significantly lower for patients more than 70 years old and age was an independent predictor of survival by multivarieate analysisS O’Keefe et al (1991)– Quarterly Journal of Medicine
7Pre-arrest Morbidity Index (PAM) Clinical characteristic PAM IndexMalignancyMetastaticLocalisedSepsisDependent functional status 5PneumoniaCreatinine > 130 umol/l 3Age >Acute MIadvanced malignancyimmobilitypneumoniarenal failuredementiaage over 70hypotensionprimary respiratory arrestNo patient with a PAM score more than 5 was discharged alive
8Patients likely to benefit from CPR Good functional statusEarly disease stageNormal renal functionAbsence of hypotensionAbsence of pneumoniaRemediable cause eg. MIEvidence indicates that patients outside these groups have a negligible chance of a successful outcome.Witnessed arrests –Ventricular arrythmiasCPR less than 5 minutes
9Patients with advanced progressive disease : CPR unlikely to be successfulBurdens outweigh the benefitsWe know when CPR would be successful or not – when should we discuss it ?Lots of evidence !!!!CPR is likely to be a less effective treatment and associated with greater risks it does have quite harmful side effects suchas rib fracture, hypoxic brain damage- risk of patient dying in an undifgnified traumatic mannerPatient should not be subjected to itTherefore in this situation :Therefore we know when CPR would be successful – therefore when should we discuss it !!!!!
10IF CPR IS FUTILENo 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 treatmentsInformed in decision-makingPreferable to emphasise end-of-life care in general when an expected part of the dying processIt is unethical to offer patients the false hope of a futile treatmentThere is no obligation to explicitly discuss a DNACPR decision with dying patientsTo offer a futile treatment is ethically inappropriateBut need to consider which patients would want or need to be informed of the decisionmaking- this is partricularly with regard to the new form
11If CPR is a viable treatment option Offer opportunity to discuss with patientPerson with capacity can refuse itperson lacks capacitydecision rests with the healthcare teamFamily 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 decisionFamily and carers have a role in informing a healthcare team decision BUT they should not be asked to make the decision (unless they have Lasting powers of attorney specific to this situation and patient has lost capacity )Decision based on likely outcome, quality of life and competence wishes of the patient.Explain all outcomes !
13Current ProblemsAll 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.To prevent repetitive conversationsThe majority of pateitns will be at the end of life when CPR is not appropriate – futile and therefore it is improtant to plan to prevent innappropriate transfers eg from nursing homes to hospital
14Yorkshire & Humber SHAThe 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.The working group has been going on for the last few yearsPlan is to have a region wide form that is going to be applicable and transferrable in ALL settingsSo why bother with a new form ?
15Aims 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).Aim is to cover 2 groups of patients :Group 2 – do not want CPRIf cant anticipate that patient not for CPR – default is for CPRThere will be no form for CPR(ie in trust losing lilac form )
16Policy objectivesAvoid 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.Communication is important – re languatge e.g still treat with IV fluids , antibiotics but not CPR – ie not about all other treatmentsThe trust policy will have a 4 page addendum regarding DNACPRAdvocates ethical practice – should not ask patient / family re resuscitation (burden )Emphasis what can be doneNeed to understand patient is dying – use the D word
17DocumentationONE 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.Pass round laminateGuidelines – not just Dr : in community can be CNS, community matronsClinical decision documentNeed to justify why not discussing patient with patient eg no capacity (elderly patient with dementia – elderly team will often discuss with family )
18Generally good practice to review – in palliative care – unlikely to change Green bottle ( fridge ) 2 stickersThe form is the patients - follows the patientsUsually box A and or CIf unsure whether successful or not discuss with patientThe form goes in front of patients notes – or in district nurses notes – when patient leaves – put ‘copy’ in notes – write copy – not red
19The processSenior 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 decisionForm needs to be kept with the patientDecision must be communicated to other key professionalsDecision must be communicated to other key professionals including those who might initiate CpR
20Regional Patient Information Leaflet Copies of leaflet
21National GuidanceDecisions 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)
22AuditY & H SHA successfully secured Regional Innovation Fund (RIF) monies to support projectEvaluation:Demonstrate an improvement in patient experience including the documentation of decisionsLocal audit directed by SHA requirements to evidence aboveOne of 5 successful bidsEvaluation formSo just to summarise :
23CPR DISCUSSIONSSituations when it’s OK not to discuss CPR with the patientCPR futilePatient states he/she doesn’t want to talk about future careMDT believes the patient may be excessively distressed by discussionPatient has clearly expressed a wish in the pastPatient lacks capacityFor this decision at this timeDiscussion not appropriate prior to documentation:atient is aware they are dying and have expressed a wish for comfort care.Important to document discussions or reasons not discussedIn those cases need to check with patient that they are happy for us to talk to familyPatient prefers not to discuss end-of-life care, giving responsibility for decisions to their doctor or carers.The patient is clearly in the terminal phase and the doctor believes that the harm of discussion outweighs the benefits.
24CPR DISCUSSIONS When does the family get to decide? Views always taken into accountNot their responsibilityLegal responsibility whenthey have been given Lasting Power of Attorney (under MCA),Acting in patient’s best intereststhe patient lacks capacity to make that decision at that timeImportant for when patient lacks capacity that if family do not have legal authority then their views should be taken into account to help advise the health care decision- but not their responsibililtyIf they do have legal responsibility and want patient to be for CPR even if this goes against what health care professionals think – would need to explore reasons – if can’t come to a conclusion – need to consider second opinion
25CPR 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.If outcome is uncertain then sensitive discussion is appropriate
26CPR Decisions Discussions Documentation Not for CPR if futile Otherwise – pt’s decisionUnless lacks capacity ADRT, Lasting Power of AttorneyDiscussionsAim to explain if CPR futileNeed to discuss if not futileDocumentationNew formUp-to- dateRegular review
27The Challenge !Challenge : informing patients and families that form exists !
28Yorkshire Post : May 2010Anger after doctors put 'Do Not Resuscitate' note on recordsA daughter has told of her "outrage" after discovering doctors treating her late mother did not plan to resuscitate her if she collapsed.
29Do not resuscitate BMJ 2001;323:58 ( 7 July ) BMJ 2001;323:58 ( 7 July )If we can’t document things properly – let the patients take the lead !!!!!