DNACPR
Post-LCP conference
Arundel Hilton
14 May 2014
Brendan Amesbury
Plan for session
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What is CPR?
Examples of poor practice
How successful is CPR? Evidence
Why are DNACPR orders needed?
Go over the SHA process and principles
Look at which patients get a DNACPR order
Range of scenarios for which DNACPR may be completed
Which patients are eligible for DNACPR orders?
Unpack principles including the single pan-Kent, Surrey & Sussex DNACPR form
Who can sign the form?
DVD: Model conversation about deterioration and resus
Does a paramedic always need to see a DNACPR form?
Accessing DNACPR forms
Where do patients keep the form at home?
Good practice examples
Consider ways of introducing DNACPR discussions
Questions
What is CPR?
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In a situation of cardiac and respiratory arrest …
External cardiac compression
Defibrillation
Artificial respiration
• Not about faints; "collapse"; unconsciousness etc
• Not IV fluids, antibiotics etc
• Not like on television (Casualty) or in newspapers
(Daily Mail!)
• There is a very low success rate even on ITU
Poor practice example 1 – giving option
• Patient with advanced malignancy, progression on CT,
albumin 14
• Admitted to hospital with new confusion and aphasia
• Investigations: concluded EOL soon. Family informed
• House officer told to “sort out the DNACPR”
• Resus option put to family by FY1 as though there was a
choice
• “We want it“
• Muddle, uncertainty …
• Registrar involved, DNACPR completed
• Patient died 2 days later
Poor practice example 2
– signing form and communication
• Hospital patient with advanced malignancy
• Medical team know patient to be dying, transfer to
hospice planned
• Daughter consulted about resus decision
• “I was asked to sign the form”
• “Signing mother’s death warrant”
• Somehow family still not aware of imminent death …
• Transfer to hospice, died after 4 hours
• Family shocked
• Quasi-complaint led to meeting at SRH incl non-exec
director with remit for EOLC
Evidence for benefit or, otherwise,
of CPR in people with advanced disease
• 0% survival for cancer patients with an anticipated arrest
due to a pre-existing condition unresponsive to treatment.
Ewer
• 2% survival after arrest for cancer patients spending more
than 50% of the day in bed. Vitelli
• 2% survival for cancer patients with an anticipated arrest
occurring in an ICU. Wallace. MD Anderson, Houston
Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of
survival after cardiopulmonary resuscitation. Cancer. 2001;92(7):1905-12.
Vitelli CE, Cooper K, Rogatko A, Brennan MF. Cardiopulmonary resuscitation and the patient with cancer. J Clin Oncol.
1991;9(1):111-5.
Wallace SK, Ewer MS, Price KJ, Feeley TW. Outcome and cost implications of cardiopulmonary resuscitation in the
medical intensive care unit of a comprehensive cancer centre. Support Care Cancer. 2002 Jul;10(5):425-9.
Why are DNACPR orders needed?
• The default option is "for resus"
• In acute care high levels of resus skills and tech – but
not all cardiac arrests warrant CPR
• In community setting a "collapsed " person – in end of
life care context someone who has died – gets
resuscitated if a 999 ambulance is called – unless a
DNACPR order is in place
• Lots of examples of distressing (to family & paramedic)
CPR in community when peaceful death was planned
South East Coast process & principles
• In 2010 South East Coast SHA End of Life Clinical Advisory
Group established a DNACPR subgroup to write "over-arching
principles" for DNACPR
• Principles to be followed by all organisations, NHS and other,
including ambulance trust
• Principles, when unpacked, are:
1. Follow BMA/RC/RCN guidelines
2. Follow Nursing & Midwifery Council guidelines about senior
nurses issuing DNACPR orders
3. Use GMC end of life guidance
4. SECAMB to be aware "no expiry date“, no need to change
address on form if patient moves to eg care home
5. Use (modified) Resus Council model form with red "active"
form & grey copy for circulation. Used by WSHT, hospices,
community
SECAMB DNACPR forms Feb 2012
Other
6%
Reason for
issue of
DNACPR form
• Cancer 36%
• Dementia 24%
• Advanced age
or frailty 7%
Patient
wishes
2%
COPD
5%
Heart
disease
5%
Unable
to read
form
5%
CVA
No 4%
Detail
6%
Dementia
24%
Age,
frailty
7%
Cancer
36%
Potential resuscitation scenarios
• Emergencies – sudden cardiac arrhythmias, RTA,
drowning
• Progressive illness where a cardiac arrest might
occur
• End-stage illness where end of life care is planned
and a cardiac arrest might occur – but also death can
be anticipated
• ADRT advance decision to refuse treatment where
patient has said "Don't want CPR"
Emergencies
• Sudden cardiac arrhythmias, RTA, drowning etc
• No advance decision about resus possible
Progressive illness
• Where a cardiac arrest might occur, but with a
good chance of successful resus – eg early heart
failure
• May be appropriate to make an advance decision
about resus – ie DNACPR order
• Patient MUST be consulted and involved in the
decision
End stage illness - EOLC
• Where EOL care is planned, a cardiac arrest might occur,
but clinical assessment is of a very low possibility of
successful CPR ie end stage heart failure, advanced cancer
• We have ethical duty to act in the patient's best interest, and
only to offer Rx that are going to be effective, therefore resus
is not a treatment the patient would be given
• Since resus is not going to be given, clinician can't discuss
resus as an option with the patient,
• Equally the clinician can't ask the patient's wishes
• But clinician may need to explain the situation to the patient
and carers and inform them that a DNACPR order is made
• Don't always have to inform patient/carers a DNACPR order
has been made – eg in the expected EOLC in-patient setting
ADRT
• Patient has made advance decision to refuse CPR
• Legally binding as part of MCA
• Must be a properly completed form witnessed,
stating aware life at risk
• Not very common at present
Which patients are near end of life and/or
eligible for DNACPR orders?
Patients are "approaching EOL" when they are likely to die within
the next 12 months.
This includes patients whose death is imminent (expected within a
few hours or days) and those with:
(a) advanced, progressive, incurable conditions
(b) general frailty and co-existing conditions that mean they are
expected to die within 12 months
(c) existing conditions if they are at risk of dying from a sudden
acute crisis in their condition
For such patients it may be appropriate to consider a
DNACPR order.
Adapted from “paragraph 2 of GMC’s Treatment and care towards the end of life"
Principle 1
BMA/RC/RCN joint
statement 2007
• Guidance for best
practice
• Widely followed
• Using it as basis for
DNACPR decisions is
straightforward
• Expecting a revision
soon
6.1 Communicating DNACPR decisions
to patients in EOLC situations
• When a clinical decision is made that CPR should not be
attempted, because it will not be successful, and the patient
has not expressed a wish to discuss CPR, it is not
necessary or appropriate to initiate discussion with the
patient to explore their wishes regarding CPR
• In most cases a patient should be informed, but for some
patients, for example, those who know they are
approaching the end of their life, information about
interventions that would not be clinically successful will be
unnecessarily burdensome and of little or no value
• Clinicians should document the reason why a patient has
not been informed of a DNACPR order if the decision is
made not to inform the patient
6.2 Requests for CPR in situations where it will
not be successful
• Neither patients, nor those close to them, can demand
treatment that is clinically inappropriate. If the healthcare
team believes that CPR will not re-start the heart and
breathing, this should be explained to the patient in a
sensitive way. These discussions informing the patient of
the healthcare team’s decision may be difficult and
where possible should be carried out by experienced
senior clinicians. If the patient (or family) does not accept
the decision and requests a second opinion, this should
be arranged whenever possible.
Principle 2
NMC guidance from 2008
• Less well-known
• Re-iterates
BMA/RC/RCN guidance
that "senior nurses with
appropriate training" may
complete DNACPR orders
• Likely to be used mainly
by hospice CNSs and
community nurses
Principle 3
GMC end of life
guidance
Published May 2010
Describes best practice
including:
• DNACPR
• Diagnosis of EOL
• Use of Prognostic
Indicator Guidance
(PIGs) from GSF
• Advance care planning
• Team work
From GMC's Treatment and care towards EOL
Paragraph 134
If … you judge that CPR should not be attempted … you
must carefully consider whether it is necessary or
appropriate to tell the patient that a DNACPR decision has
been made. While some patients may want to be told, others
may find discussion about interventions that would not be
clinically appropriate burdensome and of little or no value.
Principle 4
SECAMB guidance
from 2009
• Ambulance crews
must see original form
• No review date
unless stated
•Also no need to
change address if
move to care home.
Name, dob, NHS
number etc
Principle 5
Resus Council model
form
• Modified from original by
WSHT Resus Committee,
pall med team, PCT
• Red form is the valid form;
• Remains valid unless a
review date specified
• Will be patient-held
• "Travels" with patient – ie
applies wherever the patient
is located
• In patient's home should
be kept in Message in A
Bottle container
Principle 5 continued
Grey decision record
• Carbon copy
• Kept in patient notes
• Grey form to be
circulated to other
providers
• Can be faxed to
ambulance trust, OOH
provider, GP etc
• Form completion
guidance notes also
printed in the pads.
Who signs the DNACPR decision?
Form has two signing sections
• Section 6 for professionals in lieu of "most senior
professional" – ie OOH doctors, hospital registrars
etc.
• Section 7 for "most senior professional" ie
consultant or GP or trained senior nurse
• If those people are making the order then section 6
can be struck out
DVD
• Model conversation about deterioration and resus
• 8 minutes
• Cathy Gleeson from St Catherine’s Hospice,
Crawley
Does a paramedic always need to see
a DNACPR order?
• No. JRCALC Resuscitation Supplement stated 2010:
• “In the following condition resuscitation can be discontinued
– a patient in the final stages of a terminal illness where death
is imminent and unavoidable and CPR would not be
successful, but for whom no formal DNAR decision has been
made”
How has this been implemented at SECAMB?
In 2013 extended the DNACPR policy to include the following:
• Documentation in patient’s notes that confirms they have a
terminal illness, eg hospital, hospice or district nursing notes
• Documentation in patient notes that they have reached the
terminal phase of an illness (last weeks or days of life)
• Evidence that the patient is on LCP or other care plan used in
the last days of life
• A Preferred Priorities of Care Document, Advance Care Plan or
statement of wishes indicating patient choice not for resus
• A signed advance decision to refuse treatment (ADRT) stating
that the patient does not wish to undergo resus
Evidence that the patient is suffering from a serious illness such as
cancer is insufficient unless there is clear evidence that the patient
has entered the terminal phase of their condition
Accessing DNACPR forms
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Carbonated pads of forms printed
Distributed to hospital wards, hospices and GP practices
Sussex Community Trust – ie district nurses – have forms
Forms are located online at WSHT referral guidelines
website (palliative and end of life section) and hospice
websites
Where do patients keep the form at home?
Green Message In A Bottle containers
• Bottles funded by Lions Clubs
• DNACPR order (plus other advance care planning
tools) goes in the green bottle
• One green sticker goes on back of front door; second
sticker on front of fridge door
• Bottle goes in fridge on a door compartment/shelf
• Ambulance crews aware to look on back of front door
for a green sticker – then locate fridge
• Sourcing of supplies of containers – is on hospice and
WSHT guidelines websites
• Currently not easy to access containers in WSHT
Two recent examples of DNCAPR orders
Case 1
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RC, 69 year old with MND
Hospice in-patient with DNACPR order in place
Due to be discharged home
Patient not keen to discuss future plans, happy for wife
to be involved
• Wife aware of DNACPR order and keen to have in place
at home
• Order given to wife, along with MIAB container, to take
home
• Copy to GP, ambulance OOH etc
Two recent examples of DNCAPR orders
Case 2
• AC, 87 year old with Ca pancreas
• Patient living at home alone
• First assessment at home by hospice CNS when
patient's son also present
• Future care discussed
• Patient asked to have DNACPR order put in place
• Completed by hospice Dr, original given to patient, along
with MIAB
• Copy sent to GP, ambulance service, OOH etc
Talking to a patient about CPR status 1
Explanation about probability of dying and the changing
focus on managing symptoms and looking at some
things that would not be of benefit
• “We are concerned you may be dying now and that we
need to focus on maintaining your comfort”
• “There are some procedures that will not help and will
probably cause you more suffering such as resuscitation"
• "I'd like to talk about what would happen if you collapsed
at home – perhaps when you are very ill and had in fact
died – has anyone talked to you about resuscitation?"
Talking about a patient's CPR status 2
As part of advance care planning.
Give patient a copy of "Planning for your future care"
and follow-up once patient has read
• “If your condition deteriorated what would you want to
happen to you?"
• "Has anyone talked to you about resuscitation?"
• "What is your understanding of what CPR means?"
Talking to a patient about CPR status 3
Assessing current understanding of condition,
clarification of the current situation by suggesting a
poor outlook so providing a warning shot
• “Tell me what you understand about how your illness is
progressing and how you see the future going"
• “We are concerned about your condition, you don’t
appear to be getting any better. What do you think?”
• “We would like to talk about your future care and
management, would that be OK?”
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Last slide
Meant to be a workshop …
but some many of you interested …
Question?
What problems do you encounter in clinical
practice?
Comments?
Observations?