DO NOT ATTEMPT CARDIO-PULMONARY RESUSCITATION (DNACPR)
Background
The integrated national Scottish DNACPR policy was implemented in GGC in October
2010.
The national DNACPR policy deals only with cardio-pulmonary resuscitation (CPR) and
not any other potentially life sustaining interventions.
In the context of palliative care where death is anticipated imminently allowing a
natural death must be considered and this framework can be used to prevent futile
or unwanted attempts at CPR. CPR is a physically traumatic treatment for any who
receive it and emotionally traumatic for those families and carers who witness it.
There can be significant consequences regardless of outcome.
As with any medical intervention patients do not have a ‘right’ to CPR, however it can
be highly emotive matter and as such requires a significant amount of sensitivity.
The DNACPR framework can be considered in logical steps.
1. Is a cardio-pulmonary arrest anticipatable?
Though this sounds relatively straightforward there are some issues that require to
be borne in mind. In the context of primary care we need to consider what NHS24’s
understanding of the situation might be.
When NHS24 are telephoned regarding a death they will ask if it is expected and if
it was sudden. Even if the death is expected if it is considered to be sudden there is
the possibility of a 999 ambulance being dispatched. Viewed like this it becomes
possible for all deaths to be labeled as sudden and 999 ambulance dispatch /
resuscitation considered.
2. Will CPR realistically NOT have a successful medical outcome?
If it is felt that CPR would realistically not have a medically successful outcome then
it should not be offered as a treatment option.
This decision should then be sensitively conveyed to the patient by experienced and
suitably skilled health care professionals and, with the patients permission, their
family and loved ones.
This is a very complex issue in the community setting. Carers must know what to do,
who to contact and particularly what services should not be contacted to help prevent
unwanted and futile attempts at CPR.
3. Will CPR realistically have a successful medical outcome?
Successful CPR is not just as the initial return of spontaneous respiration and cardiac
rhythm but of prolongation of life. It may help to consider whether the patient would
be a candidate for High Dependency Care as admission to HDU is likely to be the
inevitable outcome of any initially successful CPR. If not then this would lend weight
to a DNACPR decision. This is a medical decision based upon likelihood of success. It
has nothing to do with perceived ‘quality of life’.
When considering likelihood of CPR success influential factors include: the medical
condition(s) the patient is suffering from, where they are on their disease trajectory
and the availability of resuscitation equipment and personnel to undertake CPR. (This
varies between the hospital and the community setting.)
When cardio-pulmonary arrest could be anticipated patients suffering from a life
limiting illness for whom CPR would realistically have a medically successful outcome
must have the opportunity to discuss their wishes regarding CPR and CPR should be
offered as a treatment option.
This discussion must be sensitively undertaken by experienced and suitably skilled
health care professionals e.g. GP, Community Nurse & Clinical Nurse Specialists
(CNSs) working in the community.
If the patient lacks capacity and if resuscitation is thought to realistically have a
good chance of a successful outcome then the patients legal representative e.g.
Welfare PoA or Guardian should be involved in the decision making process. Unless a
relative has a legal status they should not be burdened with decision making. If there
is no legal representative then the health care professionals caring for the patient
should make the decision that they feel is most appropriate for their patient. Clearly
great care and sensitivity is required in situations such as these.
4. Advance health care directive / decision (living will)
If the patient has an advanced health care directive / decision that is applicable in
the current clinical setting that states that CPR is not to be attempted then this
makes the matter relatively straightforward. It is also likely that the patient / loved
ones will initiate discussions.
5. Documentation and communication of the DNACPR decision
Once a decision has been reached this should be clearly documented and
communicated. If the decision is DNACPR then this should be documented on the
DNACPR form by a senior clinician involved with the patient. The DNACPR form
should be kept in the patient’s home. The decision should be entered onto the Key
Information Summary (KIS). KIS is visible to NHS24, GP Medical Out of Hours
Services, the Scottish Ambulance Service, A/E departments and Acute Receiving
Units and Specialist Palliative Care Services.
6. Review
Resuscitation decisions should be reviewed whenever the patients care setting
changes and at set time intervals dependent upon the patient’s condition.