1. Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)
Update on National Changes

2. Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)
Background
Key messages
DNACPR within the wider context of ACP
Person Centred Care

3. Background
13-17% of patients who have a cardiac arrest in hospital will survive to discharge (Ferguson et al 2008)
Living and Dying Well (SG 2008, 2011)
DNACPR Policy 2010
Tracey Judgement June 2014
BMA/RCN/RC(UK) – “Decisions Relating to CPR” 3rd ed. – July 2014
Caring for people in the last days and hours (SG 2014)

4. Background / Context
SG Health and Sport Committee Enquiry into Palliative Care
Strategic Framework For Palliative Care (SG/2015)
Montgomery vs Lanarkshire Health Board - Judgement (2015)
Winspear vs Sunderland NHS Foundation Trust - Judgement (2015)
BMA/RCN/RC(UK) – “Decisions Relating to CPR” revised 3rd ed. – July 2016

5. Summary of progress to date...
SG set up a group to perform a Light Touch Review of the DNACPR adult Policy and CYPADM Oct 2014
Representation across Scotland and services
Recognition that DNAPCR is everyone’s business
Acknowledgement that conversations about DNAPCR do not sit in isolation – should be sensitively facilitated within the wider context of Advance/Anticipatory Care Planning (ACP)
Consultation process August –September 2015
Review following further legislative changes Jan-Aug 2016
Launch of updated policy & documentation – August 2016
Shared approach to dissemination of information – everyones’ responsibility

6. The culture shift in communication - DNACPR as a prompt not a focus?
Puts death on the horizon for clinicians
Prompts escalation planning
What if they were to suddenly collapse?
- would CPR work?,
- would ITU/HDU be appropriate?
- would they be for any resuscitative measures ?(fluids, blood, NIV etc)
Prompts goals of care discussions
- out of possible realistic treatments what would the patient want?

7. NEW
1. Patients must be made aware of a DNACPR decision when CPR won’t work
If that conversation cannot take place document:
the clinical DNACPR decision without delay,
the plan to review an opportunity to have the conversation,
the reasons why the conversation can’t take place.
The only acceptable reasons for not having that conversation are:
high risk of causing psychological or physical harm
the Patient has capacity but refuses to discuss it
the Patient does not have capacity and reasonable efforts to contact welfare attorney / guardian, or those close to the patient, have failed 7

8. NEW
2. Those close to a patient who lacks capacity must be made aware of a DNACPR decision without delay when CPR won’t work
If that conversation cannot take place document;
the clinical DNACPR decision without delay,
the plan to review an opportunity to have the conversation,
the reasons why the conversation can’t take place.
The only acceptable reasons for not having that conversation are:
judged to be not practicable
judged to be not appropriate 8

9. NEW
3. Where it is clinically certain that a DNACPR decision will be appropriate until a patient’s death it does not need to be reviewed
Senior clinicians taking over clinical responsibility for the patient (transferring teams, discharge etc) must still review the decision and document that they are in agreement.
Review of decision
Review not needed as decision will remain clinically appropriate until end of life
Review needed on clinically appropriate basis 9

10. Key messages The death rate is 100%!
Almost 30% of people in a hospital bed today will die within a year (Clark et al 2014)
A DNACPR decision is intended to prevent inappropriate attempts at CPR where it clearly will not work or would not be wanted by a  patient
The DNACPR form is not a legal document and is not a decision –it is a record of a decision made in advance to provide guidance which can inform clinicians who do not know the patient and who may be summoned to assess an emergency situation
Documented evidence of communication is essential
If conversation does not take place: document rationale

11. Key messages cont’d.
Where a patient’s natural death is anticipated by the clinical team, and they are obviously imminently dying (within hours to several days), CPR is clearly contraindicated as it would not work and would only cause harm. If a DNACPR form has been overlooked in this situation the decision not to initiate CPR can be made by a nurse or junior doctor who is with the patient when this type of expected death occurs.
DNACPR forms completed prior to the launch of the new NHS Scotland DNACPR Policy (2016) will remain valid and a completed 2010 form does not need to be replaced with a new form.
Review should take place at transitions of care.

12. DNACPR…made easy D Decision making that is responsive to individual…
N Needs and is discussed within the wider context of ...
A Advance care planning that includes realistic goals of care with sensitive...
C Communication to facilitate compassionate care by...
P Preparing people in a ...
R Respectful manner to reduce the risk of an undignified death, support bereavement care, and may also reduce the risk of possible complaint
NB. The consequences of not having a form signed when a natural death is expected are:
- undignified death;
- unnecessary stress for families (especially at home);
- potential conflict between teams leading to stress for staff.

13. Person Centred Care... What matters to you? Who matters to you?
What information do you need?
Personalised contact
Nothing about me without me

14. DNACPR Education Resources
ACP toolkit and DNACPR information
Video developed for online hospital consultants’ module – open access
Online module for Foundation Year Doctors
Communication aspects of DNACPR discussions - videos available via palliative care in practice website

15. DNACPR Document links
Living and Dying Well (SG 2008, 2011)
Are we Living and Dying Well
DNACPR Policy
Tracey Judgement June
BMA/RC(UK)/RCN (June 2016)
Caring for people in the last days and hours (SG 2014)
Person Centred Care Strategy
Centred-Care-Strategy.pdf
Realistic Medicine
A National Clinical Strategy for Scotland
Atul Gawande – “Being Mortal”