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9.1.4 Additional Guidelines - for DNACPR (Do Not Attempt Cardio Pulmonary Resuscitation) - To be Referred to alongside the NHS South East Coast Principles for DNACPR

SCOPE OF THIS CHAPTER

These Guidelines relate only to Cardio Pulmonary Resuscitation (CPR) when a person’s heart and lungs have stopped. They relate to Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions in the context of an adult who is expected to die from advanced or incurable progressive chronic disease. DNACPR orders may also be initiated at the request of the person. The Guidelines do not relate to any other types of intervention or care, which should be given to the person as needed, or in accordance with their wishes.

These are Additional Guidelines for DNACPR. They should guide policy in both Adult Social Care (including independent sector), and Nursing Home Services in Brighton and Hove.

NHS South East Coast Principles of DNACPR

AMENDMENT

This chapter was updated in October 2015 to include a link to the NHS South East Coast Principles of DNACPR.


Contents

  1. Introduction
  2. Under What Circumstances Should a DNACPR Decision be Requested (Initiated)?
  3. Who Can Decide Whether a DNACPR Agreement should be in Place, Under Each Circumstance?
  4. What is it Right to Expect of a GP/Consultant?
  5. How Can Care Services and Staff Assist the Process?
  6. Who Needs to Know if there is a DNACPR in Place?
  7. What if there is no DNACPR Order and the Person’s Heart has Stopped Beating?
  8. Who Should we Call if a Person Dies and has a DNACPR in Place?
  9. What Should we Do if the Person Collapses and their Heart and Breathing Hasn’t Stopped?
  10. Where Should we Keep the DNACPR Form?
  11. Is There Ever a circumstance When the DNACPR Form Should be Overridden?
  12. Does a DNACPR have to be Reviewed?
  13. What if the Person has Instigated a DNACPR, but Changes their Mind?
  14. How do Advance Decisions to Refuse Treatment (ADRTs) Fit in with DNACPRs?

    Appendix 1: Flow Chart showing what care staff should do if a person dies in different circumstances


1. Introduction

These additional guidelines are to assist care providers in knowing what to do when dealing with DNACPR decisions. We need to get this process right and allow people to have a dignified death, knowing that people are empowered to be involved with decisions about their own death and end of life care, where there are choices to be made. Principles of individual choice, dignity and respect need to underpin end of life care as with any other person centred support planning.

All decisions must centre on the wellbeing of each person as an individual. There should always be evidence of individualised consideration when forms are signed, as each person’s specific circumstances will be different.

These additional guidelines are to clarify aspects of the decision making process for DNACPRs in different circumstances.

They are in the form of Questions and Answers.


2. Under What Circumstances Should a DNACPR Decision be Requested (Initiated)?

When it is thought that attempting Cardio Pulmonary Resuscitation (CPR) would be medically inappropriate and would not work, and is likely to prevent the person being allowed to have a natural and dignified death. In this instance there are no realistic choices or options to be considered. (CPR is a medical treatment and medical practitioners must reach their own decisions, and cannot be compelled to offer this treatment to an individual where it is judged not to be clinically appropriate or in the person’s best interests).

When a person, who has mental capacity, initiates a request to have a DNACPR in place, at any point; or when as part of sensitive end of life care planning discussions, the person has indicated that they would wish/ feel ready to be allowed to die naturally without CPR. This may be due to quality of life decisions.

When the person is deemed to be nearing the end of their life, but it is not completely clear if CPR would be a clinically appropriate or helpful intervention. In this instance, quality of life issues should be discussed and the opinion of the person should guide the decision if he/she has capacity. If not, views from those close to them or from other relevant professionals involved in their care need to be sought in order for the clinician in charge to make a best interests decision (see Section 3.3 Where Quality of Life Judgements are Involved in Decision Making).

When the person may survive CPR, but their quality of life would be seriously reduced. Quality of life issues should be discussed as in the paragraph above.


3. Who Can Decide Whether a DNACPR Agreement should be in Place, Under Each Circumstance?

The only people who can ever make the decision not to be for CPR are:

  • The Person (when they possess capacity to make this decision);
  • The GP, or a Consultant (or a nurse who is specifically trained and qualified for this);
  • The appointed attorney where this specific decision making power is contained in a valid and registered Lasting Power of Attorney for Health and Welfare and the person lacks capacity to make this decision.

As part of overall care planning for the person, there should be sensitive discussion and plans about wishes for care at the end of life, along with other aspects of future care. These discussions can involve chosen family members/ representatives, if appropriate (see point 3.1).

3.1 When a DNACPR order is Issued based on grounds of “Futility” (judged to be clinically inappropriate)

See also Section 2, Under What Circumstances Should a DNACPR Decision be Requested (Initiated)? paragraph 1.

The decision as to whether CPR would be clinically appropriate is purely a medical one. The term “futile” has traditionally been used by clinicians to describe an intervention that would be unhelpful or ineffective as it would carry with it more burden than benefit. However, this term is increasing felt to have negative connotations for carers and patients and therefore the terms “futile” and “futility” are best avoided.

Where CPR is judged to be clinically inappropriate, the decision is for the, the GP or consultant to make. However, in practice these decisions are often made with input from the multi professional team.

The decision to put a DNACPR order in place must be sensitively explained to the person, unless it is felt that this would do them harm, ‘there should be a presumption in favour of patient involvement…there need to be convincing reasons not to involve the patient’ (Case Law : R (David Tracey) v Cambridge University Hospitals NHS Foundation Trust & Ors [2014] EWCA Civ 822)

The reason for not involving the person (or their chosen family/representatives) must  be fully recorded. For a person not to be involved, the clinician would have to consider that to do so is likely to cause a person to suffer physical or psychological harm.

The benefits, and imposed burdens for the person in having this discussion have to be ‘weighed up’ at the time. The discussion should still not be forced on a person who is clearly not wanting to have it. There may also be occasions where the person has expressed a specific wish not to discuss end of life care issues, and this should be respected.( If a person lives alone and has capacity it is clearly  important to ensure they are aware of the DNACPR decision if the DNACPR form is to be left in the home with them).

It is best practice to sensitively discuss and inform relatives/people close to the person (including care staff), that this decision has been deemed necessary, and what this will mean for the person’s’ end of life care. The aim should be to secure an understanding by the person of the clinical decision which has already been made. The decision maker should do this, or agree who else may be more appropriate to have initial discussions. If there are any issues for the relatives then they should be directed to the decision maker. (The person receiving care should guide services, as to who they would generally like to be consulted and informed about their care, as part of early care planning discussions. We also need to remain aware of the need not to break confidentiality and respect the person’s right to choose who should be told about their care).

In the case where CPR would be clinically inappropriate, it is  reasonable for a person, their family or professional carer’s to ask a medical practitioner to explain why they have judged CPR to be futile and to ask for another medical opinion if doubt remains about the appropriateness of the decision after this discussion.

If the person lacks mental capacity to understand this decision, it is not necessary, (although possible if the GP/consultant wish), to involve an Independent Mental Capacity Advocate (IMCA) if CPR has been judged to clinically inappropriate, even if the person doesn’t have relatives to support them.

3.2 When the Person has Mental Capacity, and has Requested that a DNACPR is Put in Place

See also Section 2, Under What Circumstances Should a DNACPR Decision be Requested (Initiated)? Paragraph 2 above.

The decision is for the person and their GP/consultant. Once the GP/Consultant has established that the there is no evidence to suggest that the person may lack capacity to make this decision, the form should be signed by the doctor, and other relevant professionals should be made aware of the person’s decision. If the doctor suspects the person is suffering from an underlying mental health illness e.g. depression, which is affecting their decision, a mental health assessment should be sought.

If they so wish, the person can draw up a more formal Advance Decision to Refuse Treatment (ADRT) – see Section 13, What if a Person has Requested a DNACPR to be in Place but they Change their Mind?

It is helpful if the person has been able to discuss this with their family, representatives and people close to them, in order that they can respect their wishes. They may need encouragement/help to do this.

3.3 Where Quality of Life Judgements are Involved in Decision Making

See also Section 2, Under What Circumstances Should a DNACPR Decision be Requested (Initiated)? paragraphs 3 and 4 above.

The GP/ medical consultant and the person continue to be the decision makers and should have some discussion. In cases where it is not completely clear that CPR would not work  but where quality of life may be significantly affected, it is important to understand what the person’s views are.

It is helpful if the person has been able to discuss this with their family, representatives and people close to them in order that they can respect their wishes, (as in 3.1), however if they have capacity this is not mandatory. They may need encouragement/help to do this.

Where the person has been assessed to lack capacity in accordance with the Mental Capacity Act 2005, regarding this end of life decision, those close to the person should be consulted in order to achieve a Best Interest Decision (A decision which it is believed the person would have made, if they had the ability to do so). If the person has appointed a Lasting Power of Attorney (LPA) this attorney should be consulted first, according to The Mental Capacity Act 2005. It may be that the person has a valid Advance Decision to Refuse Treatment, and this should be respected. The decision maker will also weigh up the burdens and benefits of an intervention as well the benefits and burdens of not treating. They should also take into account any current ascertainable wishes, feelings or known values of the person concerned

If the person does not have the capacity to make the decision, and has no family or has not appointed an LPA, then an Independent Mental Capacity Advocate (IMCA) must be requested to be involved, in line with the Mental Capacity Act. In assessing the person’s capacity to make this decision, explanations should be communicated in a way (and at times of the day) that the person is most likely to understand. People who know the person best may be the best people to advise on this, or to support this discussion.

A referral for an Independent Mental Capacity Advocate can be made by the GP completing an IMCA referral form (which they should have copies of, or they can get copies of on the POWER website).


4. What is it Right to Expect of a GP/Consultant?

To work within the NHS South East Coast Principles, The Mental Capacity Act 2005, National Guidelines and professional codes of conduct –which are compatible with these Guidelines.


5. How Can Care Services and Staff Assist the Process?

People working in care services who know the individual person well, may sometimes be the right people to assist doctors in their role e.g. help by starting sensitive discussions with the person and hear what the persons wishes are, in the course of general care planning and discussion with them. (Staff would need to feel confident and competent to undertake these discussions. It may be that training is identified in order to assist in this competence).


6. Who Needs to Know if there is a DNACPR in Place?

  • The original signed form should transfer with the person to other care settings/Drs etc;
  • The person, as appropriate – see Section 3.1, When a DNACPR Instruction is Issued due to Medical Futility;
  • The ambulance service – (They must see the original signed document or they are unlikely to accept its validity). (You can fax and E-mail a copy of the DNACPR form to SECAmb so that they will look for the document on arrival at the incident. Fax 01273489445);
  • Relatives/the person’s chosen representatives- as appropriate;
  • All care staff;
  • The out of hours GP service and DN service;
  • The in hours GP service and DN service.
Specialist medical services involved in the persons care e.g. care home support team/ community mental health team and specialist palliative care team.


7. What if there is no DNACPR Order and the Person’s Heart has Stopped Beating?

Call for an Ambulance and give first aid.

The ambulance service will generally try CPR if they attend, and a person’s heart has stopped or they have collapsed or died.

However, in February 2013 the local ambulance service (SEAcamb)  clarified some circumstances and medical conditions where the ambulance staff can make a judgement,  and resuscitation does not need to be attempted (or may be discontinued), as long as there is proof of these. 

These circumstances can be that there is:

  • Documentation in patient’s notes that confirms they have a terminal illness. This can include hospital or hospice notes, district nursing notes etc, but the crew must see these;
  • Documentation in patient notes that they have reached the terminal phase of an illness (last weeks or days of life);
  • Documentation in patient notes that the patient is on a Liverpool Care Pathway or other care plan used in the last days of life;
  • A Preferred Priorities of Care Document, Advance Care Plan or statement of wishes that sets out the patient’s choice not to be to be resuscitated;
  • A signed Advance Directive to Refuse Treatment (ADRT) stating that the patient does not wish to undergo attempted resuscitation.


8. Who Should We Call if a Person Dies and has a DNACPR in Place?

(Also see flow chart in Appendix 1: Flow Chart Showing What Care Staff Should do if a Person Dies in Different Circumstances).

  • The Ambulance service if it is unexpected, the GP if it is an expected death;
  • If in doubt, call the ambulance service;
  • Be prepared to show the Ambulance service the DNACPR form (which must be the original);
  • You will obviously need to also call relatives and significant others as well, in accordance with normal procedures in the event of a death;
  • If the death is in a service which is registered with the Care Quality Commission, you will need to complete and send a CQC Notification;
  • If there are any suspicious circumstances (even if death was otherwise expected), the police will also need to be called in addition to the ambulance.


9. What Should We Do if We Find Someone Collapsed and their Heart or Breathing Hasn’t Stopped?

Give first aid and call an ambulance as normal. Remember, DNACPR orders relate only to Cardio Pulmonary Resuscitation (restarting the heart and breathing). Other types of intervention are not covered by a DNACPR order. A person should obviously still receive all necessary treatments to keep them comfortable, and to treat any reversible condition.


10. Where Should We Keep the DNACPR Form?

Where all care staff (and carers if at the person is at home) can find it to show the ambulance service if they are called.

If the DNACPR form is to be in their file, then its location must be clearly indexed, or at the front.

The original red bordered form must transfer with the person to other care settings.


11. Is There Ever a Circumstance When the DNACPR Form Should be Overridden?

Yes. If the deterioration is not felt to be due to natural causes or if the cause is a sudden unexpected and reversible event (such as the blockage of the wind pipe by choking on food), or if any pre-existing Advance Directive to Refuse Treatment is not felt to be valid or applicable to the situation in hand

Remember, DNACPR’ orders relate only to Cardio Pulmonary Resuscitation (restarting the heart and breathing in the context of expected death from advanced or incurable progressive chronic disease). Other types of intervention are not covered by a DNACPR order.


12. Does a DNACPR have to be Reviewed?

Not if the form states “Indefinite”. Otherwise the DNACPR must be reviewed if  a review date is  specified, or if circumstances change e.g. there is a change in health status, the person changes their mind, or, if the decision is challenged.


13. What if a Person has Requested a DNACPR to be in Place but they Change their Mind?

This is a change of circumstances, and it should be reviewed promptly in discussion with the person, if there were quality of life factors taken into account for the original decision. If the reason for the decision was purely due to medical futility, then this may not alter things, but there needs  to be further discussion and explanation with the person. (The person does not have the right to demand treatment, but the decision maker – doctor- will be accountable for the decision).


14. How do Advance Decisions to Refuse Treatment (ADRTs) Fit in with DNACPRs?

When the person has mental capacity, and has requested that a DNACPR is put in place (as said in Section 2, Under What Circumstances Should a DNACPR Decision be Requested (Initiated)?):

The decision is for the person and their GP/consultant. The form should be signed by the Doctor. If they so wish, the person can also draw up a more formal Advance Decision to Refuse Treatment (ADRT). This  remains effective if the person subsequently loses mental capacity to make decisions concerning the specific treatment identified in the ADRT document, which may include CPR. The way to make a valid ADRT is laid out in The Mental Capacity Act 2005 Code of Practice.

Healthcare and social care professionals must follow an advance decision if it is valid. A DNACPR signed by a doctor should ideally  still  be in place, even if an ADRT exists.

Most people who use services should also have an advance care plan (advance statements) as part of normal care planning, which records their wishes for their general care at the end of life.

Definitions of ADRTs and advance care plans (advance statements) and Advance Care Planning are also available on National Guidance and Core Competencies and Principles for End of Life Care (NHS).


Appendix 1: Flow Chart Showing What Care Staff Should do if a Person Dies in Different Circumstances

Click here to view flow chart

It is Important to remember that all cases still need to be assessed individually and no flow chart could cover all possibilities.

End