Consultant in Palliative Medicine Calderdale & Huddersfield NHS DNACPR The new form Dr Jeena Ackroyd Consultant in Palliative Medicine Calderdale & Huddersfield NHS Foundation Trust

There has been a lot of discussion about the decision making and documention on CPR and this can often be difficult It is important to know when to and when not to offer resuscitaion

Outline Success rates of CPR When would CPR be futile? Who makes the decision? When do we need to discuss ? The new DNACPR form Presumption in favour of CPR Do not attempt CPR if it will not restart the heart/breathing Discussion about CPR with patients is not always necessary CPR is "futile" when it offers the patient no clinical benefit. When CPR offers no benefit,

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 you 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.

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 ? 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

Retrospective 274 patients receiving CPR 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 41 patients with cancer 37 with pneumonia 25 patients left hospital alive Survival to discharge significantly lower for patients more than 70 years old and age was an independent predictor of survival by multivarieate analysis S O’Keefe et al (1991)– Quarterly Journal of Medicine

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 advanced malignancy immobility pneumonia renal failure dementia age over 70 hypotension primary respiratory arrest No patient with a PAM score more than 5 was discharged alive

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 Evidence indicates that patients outside these groups have a negligible chance of a successful outcome. Witnessed arrests – Ventricular arrythmias CPR less than 5 minutes

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 ? 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 manner Patient should not be subjected to it Therefore in this situation : Therefore we know when CPR would be successful – therefore 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 It is unethical to offer patients the false hope of a futile treatment There is no obligation to explicitly discuss a DNACPR decision with dying patients To offer a futile treatment is ethically inappropriate But need to consider which patients would want or need to be informed of the decisionmaking- this is partricularly with regard to the new form

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 Family 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 !

New DNACPR form : Why do we need this form ?

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. To prevent repetitive conversations The 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

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. The working group has been going on for the last few years Plan is to have a region wide form that is going to be applicable and transferrable in ALL settings So why bother with a new form ?

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). Aim is to cover 2 groups of patients : Group 2 – do not want CPR If cant anticipate that patient not for CPR – default is for CPR There will be no form for CPR (ie in trust losing lilac form )

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. Communication is important – re languatge e.g still treat with IV fluids , antibiotics but not CPR – ie not about all other treatments The trust policy will have a 4 page addendum regarding DNACPR Advocates ethical practice – should not ask patient / family re resuscitation (burden ) Emphasis what can be done Need to understand patient is dying – use the D word

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. Pass round laminate Guidelines – not just Dr : in community can be CNS, community matrons Clinical decision document Need to justify why not discussing patient with patient eg no capacity (elderly patient with dementia – elderly team will often discuss with family )

Generally good practice to review – in palliative care – unlikely to change Green bottle ( fridge ) 2 stickers The form is the patients - follows the patients Usually box A and or C If unsure whether successful or not discuss with patient The form goes in front of patients notes – or in district nurses notes – when patient leaves – put ‘copy’ in notes – write copy – not red

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 Decision must be communicated to other key professionals including those who might initiate CpR

Regional Patient Information Leaflet Copies of leaflet

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 One of 5 successful bids Evaluation form So just to summarise :

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 Discussion 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 discussed In those cases need to check with patient that they are happy for us to talk to family Patient 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.

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 Important 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 responsibililty If 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

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. If outcome is uncertain then sensitive discussion is appropriate

CPR Decisions Discussions Documentation 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 Regular review

The Challenge ! Challenge : informing patients and families that form exists !

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.

Do 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 !!!!!

Any Questions ? Hard decisions and discussions

DVD