1. DNA CPR Decisions 19 th March 2014 Dr Ruth Caulkin Palliative Medicine StR

2. BMA/ Resuscitation Council/RCN guidance “The decision to use any treatment should be based on the balance of burdens, risks and benefits to the individual receiving the treatment, and that principle applies as much to CPR as to any other treatment.” Treatment is justified only if there is expected benefit to the patient, i.e. we must justify attempting CPR, as opposed to justifying not attempting it.

3. Who makes the decision? “ The overall clinical responsibility for decisions about CPR, including DNAR decisions, rests with the most senior clinician in charge of the patient’s care as defined by local policy. The most senior clinician could be a consultant, GP or suitably experienced nurse. In certain settings an experienced nurse may be the senior clinical decision maker. Examples include nurse consultants or senior clinical nurses working in palliative care. If there is genuine doubt or disagreement about whether CPR would be clinically appropriate a further senior clinical opinion should be sought.”

4. Group 1- those for whom there is no reason to believe the patient will arrest Do not initiate the CPR discussion. CPR will be attempted if arrest occurs as there is no reason to believe it could not succeed (unless a patient without capacity has a valid and applicable Advance Decision refusing CPR, or an LPA). Be willing to discuss if patient initiates the conversation.

5. Group 2 – those for whom there is no realistic chance that CPR could be successful. Make a DNAR decision. Do not offer CPR, or ask patients if they want it to be attempted. If patient has capacity, consider explaining decision to patient. If patient lacks capacity, inform family if appropriate, inform LPA or Court Appointed Deputy. Provide second opinion if requested.

6. Group 3- those for whom CPR might be successful but the potential burdens and risks of attempting CPR might outweigh the benefits The involvement of these patients in the decision is crucial – the view of the patient should guide the decision. If the patient lacks capacity, make a best interests judgement according to the Mental Capacity Act process, unless an LPA has authority to make the decision or a valid and applicable Advance Decision refusing CPR exists.

7. Do I need to discuss DNAR when CPR will not work? In most cases the patient should be informed but for some patients, for example those who are approaching the end of their life, such information may be unnecessarily burdensome and of little or no value Need to document reason why a patient has not been informed of a DNAR order

8. Adults who lack capacity, have no LPA or AD, but do have family/friends The treatment decision rests with the most senior clinician in charge of the patient’s care In making a best-interests decision - named people, carers and those interested in the patient’s welfare should be consulted (MCA) “It should be made clear to those close to the patient that their role is not to take decisions on behalf of the patient, but to help the healthcare team to make an appropriate decision in the patient’s best interests. Relatives and others close to the patient… cannot insist on treatment or non-treatment.”

9. What constitutes a valid DNAR?

10. Type of DNAR orderYesNo 1) Written on standard form with the ambulance trust logo signed by a medical practitioner? 34.6% (37) 63.6% (68) 2) Written on a standard form with the ambulance trust logo signed by a district nurse? 3.7% (4) 94.4% (101) 3) Written on a standard form with the ambulance trust logo signed by a specialist palliative care nurse? 19.6% (21) 76.6% (82) 4) Written on PCT or hospital headed note paper signed by a consultant?78.5% (84) 19.6% (21) 5) Written on PCT or hospital headed note paper signed by a registrar?65.4% (70) 32.7% (35) 6) Written on PCT or hospital headed note paper signed by a district nurse or ward sister? 2.8% (3) 95.3% (102) 7) Written on PCT or hospital headed note paper signed by a specialist palliative care nurse ? 27.1% (29) 68.2% (73) 8)Written on General Practice headed note paper and signed by GP?75.7% (81) 22.4% (24) 9)Written on a blank sheet of paper signed by any of the above who you consider able to sign a DNAR order? 15.9% (17) 81.3% (87) 10) An Advanced Decision to Refuse Treatment on a standard form which specifies DNAR written and signed by the patient 2 mths before 52.3% (56) 43% (46) 11) DNAR written on blank sheet of paper by patient?12.1% (13) 81.3% (87) 12) A DNAR communicated to you by the ambulance control?15.9% (17) 81.3% (87) 13) A verbal DNAR given to you at the seen by any health professional who you consider able to sign DNAR order? 19.6% (21) 78.5% (84) 14) A verbal DNAR given to you over the telephone by any health professional who you consider able to sign DNAR order? 7.5% (8) 90.7% (97) Audit of Warwickshire ambulance crew’s interpretation if DNAR order valid (EAPC Lisbon 2011)

12. What is best practice? Complete DNAR CPR form if appropriate (standardised Resus council form) Leave original copy in the Home Complete CMC record with CPR status DNAR CPR form should be reviewed and endorsed by most Senior HCP as soon as reasonably possible CPR status should be reviewed on transfer between clinical settings

13. Relevant documents NHS Scotland DNACPR integrated adult policy (2010) http://www.scotland.gov.uk/Publications/2010/05/24095633/0 Resuscitation Council (UK) guidance (2010) Resus Council – model DNAR form https://www.resus.org.uk/pages/dnarrstd.htm https://www.resus.org.uk/pages/dnarrstd.htm Joint statement from BMA, Resus Council & RCN (2007) http://www.resus.org.uk/pages/dnar.pdf London Ambulance Service policy (2010) http://www.londonambulance.nhs.uk/

14. We should all know how to do this…. …… but that doesn’t mean it’s always easy!