1. The NSW Resuscitation Plan- Paediatric Information for Health Professionals

2. Outline 1.The Resuscitation Plan – paediatric and adult 2.Case Study 3.Background 4.Why a statewide form? 5.Key issues 6.Ordering the Resuscitation Plan 7.Where to get more information?

3. Statewide Resuscitation Plans There are 2 Resuscitation Plans available: Resuscitation Plan Paediatric: Currently for infants > 29 days old and young persons up to 18 years (SMR020.055) Resuscitation Plan Adult: 18 years and older (SMR020.056) 3

4. Case Study Sarah is a 9 year old girl with recurrent lower respiratory tract infections on a background of chronic lung disease and a neurodegenerative disorder. She is deteriorating neurologically with increased muscle weakness and requires nocturnal BiPap. She has had recurrent admissions to hospital with lower respiratory tract infections. She lives 1 hour from the children’s hospital. Large tertiary hospital within 15 minutes. 4

5. Triggers to consider a Resuscitation Plan- Paediatric If the treating clinician were to ask, ‘Would I be surprised if Sarah were to die in 6-12 months?’ and the answer is ‘No’. A steady deterioration in chronic illness. An increased risk (recurrent admissions and her prognosis is uncertain). Clinical deterioration in her condition would require an activation of a Rapid Response System, or is anticipated to do so. Established goals are identified for end of life care. Clear communication is needed for all hospital/community health providers involved in care. 5

6. 6 Resuscitation Plan – Paediatric (SMR020.055)

7. 7 Resuscitation Plan – Adult (SMR020.056)

8. Background The NSW Resuscitation Plan: An outcome of the NSW Health Advance Planning for Quality Care at End of Life: Action Plan 2013-2018. A working group was established to review the existing Policy Guideline Decisions relating to No Cardio-Pulmonary Resuscitation (CPR) Orders. An extensive consultation process was carried out with relevant NSW health clinicians on draft documents leading to the final Resuscitation Plans. 8

9. Why a Statewide Form? Patients are cared for across various health locations in NSW (hospital, community, ambulance service). A statewide form aims to improve communication between all health providers involved in care by:  Supporting common terminology related to advance care planning/end of life.  Reducing confusion for health providers.  Improving consistency in End of Life care documentation. 9

10. NSW MOH Policy Directive (PD) The policy directive and the forms contained within it are for the use of NSW Health staff All NSW Public Health Organisations must comply and implement the Resuscitation Plan (acute facilities, sub-acute facilities, ambulatory, community settings, NSW Ambulance) All other equivalent forms (no CPR/ End of Life Care Plans) will be replaced by the Resuscitation Plan. NSW Resuscitation Plans are not valid for community patients under the medical care of a doctor that is not a NSW Health staff member. General Practitioners with admitting rights are considered NSW Health staff. 10

11. Key issues for use 1.Evidence of prior planning Consider previous documentation (e.g. Allow a Natural Death Form or Advance Care Plan). Conversations held with parents/guardians as appropriate. 11

12. 12 2.Capacity and participation Attending Medical Officers prescribing medical orders, including ‘Resuscitation Plans’, hold responsibility for reaching those decisions, in consultation with parents/guardians. Usually decisions are made by parents/guardians (a child will not always have capacity for decision making). When appropriate, decision making with children/young people can occur in consultation with parents/guardians. If Family and Community Services (FACS) are involved, please refer to the back page of the Resuscitation Plan-Paediatrics.

13. 13 3.Clinical interventions and monitoring Vital sign monitoring on the Standard Paediatric Observation Chart should be consistent with what is stated in the Resuscitation Plan. Nurses may call for medical review of unrelieved symptoms, even if activating an urgent Clinical Review call has been considered unnecessary.

14. 14 4.Referral/transfer/discharge NSW Resuscitation Plans are valid for NSW Ambulance staff in all situations involving patient contact. Parents/guardians should be provided with a copy of the document. A hard copy of the Resuscitation Plan should accompany the patient on inter-facility transfer or discharge home. Resuscitation Plans are valid in the community setting unless a community patient is under the medical care of a doctor that is not a NSW Health staff member. General Practitioners with admitting rights are considered NSW Health staff.

15. 15 5.Authorising and signing the Resuscitation Plan The Attending Medical Officer (AMO) has responsibility for a patient, even if other medical officers are involved. The most experienced clinician should generally discuss resuscitation with the child’s parent/carer. Delegation to a JMO should only occur with adequate training, supervision and support. If a JMO is required to discuss and document a Resuscitation Plan (e.g. out of hours) this must be discussed with the AMO at the earliest opportunity.

16. 16 Other health care professionals (including nurses) cannot be delegated the task of informing parents/guardians or obtaining consent for resuscitation planning. Parents/guardians are not required to sign the Resuscitation Plan All resuscitation discussions should be documented in the child’s medical record Please see Medical Consent Policy http://www0.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406. pdf) http://www0.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406. pdf

17. 17 6.Reviewing the Resuscitation Plan Generally the information on a completed Resuscitation Plan needs to be clarified from one acute admission to the next (where a change in prognosis is likely). Information on the Resuscitation Plan may need to be checked more or less frequently for some patients and individual family circumstances. If parents/guardians request a change. Refer to the back of the Resuscitation Form for further information.

18. 18 7.Revoking or amending the Resuscitation Plan For significant amendments (e.g. a change to the CPR order), the Resuscitation Plan must be revoked and a new Plan completed. The procedure for revoking the Resuscitation Plan is to rule a diagonal line through both sides, then print and sign your name and date on the line. For less significant amendments (for example, a change to the intervention section), the Resuscitation Plan can be amended and initialled. This should be documented in the medical record.

19. 19 8.Storage of Resuscitation Plans Each hospital has different processes in place for storing the Resuscitation Plan. It is recommended that the current hard copy should be kept at the front of the patient’s health record. It is preferable that multiple copies are not made. Details of the Resuscitation Plan should be included in handover between shifts. Must be integrated into electronic health record systems on appropriate forms. It is recommended to be incorporated into hospital discharge summaries, where possible.

20. How to order the Resuscitation Plan Forms can be ordered through Stream Solutions: Paediatric: (Product Code: NH606747) Resuscitation Plan – Paediatric (SMR020.055) pack of 20. Adult: (Product Code: NH 606746) Resuscitation Plan – Adult (SMR020.056) pack of 100. 20

21. Where to get more information? The Resuscitation Plan Policy Directive (PD 2014_030) http://www0.health.nsw.gov.au/policies/pd/2014/PD2014_030.html http://www0.health.nsw.gov.au/policies/pd/2014/PD2014_030.html The NSW Paediatric Palliative Programme: The Children’s Hospital at Westmead John Hunter Children’s Hospital, Newcastle Phone: 9845 0000 Phone: 4921 3387 Business hours: 830am-5pm Business hours: 830am-5pm Email: schn-chwppc@health.nsw.gov.au Email: HNELHD-PaedPallCare@hnehealth.nsw.gov.auschn-chwppc@health.nsw.gov.auHNELHD-PaedPallCare@hnehealth.nsw.gov.au Sydney Children’s Hospital, Randwick Phone: 9382 0035 Business hours: 830am-5pm Email: SCHN-CNCPalliativeCare@health.nsw.gov.au SCHN-CNCPalliativeCare@health.nsw.gov.au 21

22. Acknowledgements The NSW PPC Programme would like to acknowledge that some of the content from this presentation was created by Julie Letts and the project team for the development of the NSW Resuscitation Plan, NSW Ministry of Health 22