NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
Integrated Policy on
Do Not Attempt CardioPulmonary Resuscitation
(DNA CPR)
Decision-making
& Communication
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
CONTENTS
PAGE
Introduction ...................................................................................... 3
Objectives of the Policy .................................................................... 5
Cardio-Pulmonary Resuscitation: what it is and what it is not ........... 6
The Principles of making a DNA CPR Decision ................................ 6
The Decision-Making Framework ..................................................... 9
The DNA CPR Form ......................................................................... 9
Reviewing the Decision .................................................................. 10
Withholding of Resuscitation .......................................................... 10
Responsibility for Decision-Making:
Patients and their Relatives/Carers ................................................ 11
Children .......................................................................................... 12
Responsibility for Decision-Making: Professional ........................... 12
Annex A: NHS Scotland Framework for Cardio-Pulmonary
Resuscitation (CPR) Decisions ...................................................... 13
Annex B: Supporting information when making CPR decisions
and completing a DNA CPR Form .................................................. 14
Medical Prediction of the Outcome of Resuscitation....................... 17
Disclaimer ...................................................................................... 18
Appendix I: The DNA CPR Form ................................................... 19
Appendix II: The Decision-Making Framework.............................. 21
Appendix III: Patient Information Leaflet ....................................... 23
References ..................................................................................... 35
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
INTRODUCTION
Why is an integrated DNA CPR policy needed?
Cardio-pulmonary resuscitation (CPR) could be attempted on any individual in whom cardiac
or respiratory function ceases. Such events are inevitable as part of dying and thus,
theoretically, CPR could be used on every individual prior to death. It is therefore essential to
identify patients for whom cardio-pulmonary arrest represents the terminal event in their illness
and for whom CPR will not work and/or is inappropriate. It is also essential to identify those
patients who would not want CPR to be attempted in the event of an arrest and who
competently refuse this treatment option. Some competent patients may wish to make an
advance statement about treatment (such as CPR) that they would not wish to receive in
some future circumstances. These statements must be respected as long as these decisions
are informed, current, made without coercion from others and clearly apply to the current
clinical circumstance.
This policy is intended to prevent inappropriate futile and/or unwanted attempts at CPR which
may cause significant distress to patients and families because the patient’s death has been
without dignity, traumatic and even painful. When a patient dies at home or in a care home an
inappropriate CPR attempt is likely also to involve the Scottish Ambulance Service
paramedics and even the police, which can add greatly to the distress for the families and be
upsetting for all those involved. This policy is intended as a positive step to help a person’s
wishes be followed at the end of life irrespective of whether they are being cared for in
hospital, hospice, care home or in their own homes.
There is much confusion and uncertainty about CPR and the process of making advance
decisions that CPR should not be attempted. Variations in local policies can cause
misunderstandings and lead to distressing incidents for patients, families and staff. Increased
movement of patients and staff between different care settings in Scotland makes a single
integrated and consistent approach to this complex and crucial area a necessity. This policy
is in line with current national good practice guidance on decisions relating to CPR, such as
the revised Joint Statement produced by the British Medical Association, Royal College of
Nursing and Resuscitation Council (UK) (2007); and the guidance within “End of life
treatment and care: good practice in decision-making” from the General Medical Council
(2010).
In 2006 NHS Lothian implemented the UK’s first fully integrated Do Not Attempt
Resuscitation (DNAR) policy with the support of the Scottish Ambulance Service and in 2008
an integrated approach to DNAR was published as an action point for Health Boards within
Living and Dying Well, a national action plan for palliative and end of life care in Scotland. In
2009, in response to a specific recommendation from the Public Audit Committee following the
Audit Scotland publication Review of Palliative Care Services in Scotland the Scottish
Government began working on developing a national integrated policy for Do Not Attempt
Cardio-Pulmonary Resuscitation (DNA CPR) decision-making and communication.
Within this policy the term “Do Not Attempt Cardio-Pulmonary Resuscitation” (DNA CPR) is
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
used rather than “Do Not Attempt Resuscitation” (DNAR) to help clarify for patients, families
and professionals that this policy refers solely to cardio-pulmonary resuscitation (CPR) in the
event of a cardio respiratory arrest. It does not refer to other aspects of care e.g. analgesia,
antibiotics, suction, treatment of choking, treatment of anaphylaxis etc which are sometimes
loosely referred to as “resuscitation”.
The advice in this policy should be used in conjunction with the NHS Scotland DNA CPR
form, decision-making framework and patient information leaflet, which can all be found within
and appended to this policy. The purpose of the policy is to provide guidance and
clarification for all staff working within NHS Scotland regarding the process of making and
communicating DNA CPR decisions.
Where patients are admitted to hospital or hospice acutely unwell or become medically
unstable in their existing home or healthcare environment their resuscitation status should be
considered as soon as is reasonably possible. When no explicit decision has been made
about CPR before a cardio-pulmonary arrest occurs, and the express wishes of the patient
are unknown, it should be presumed that staff would initiate CPR. However, where CPR
would clearly not work it should not be attempted and experienced healthcare workers who
make this considered decision should be supported by their colleagues.
Throughout this document the term “relevant others” is used to describe patient’s relatives,
carers, representatives, advocates, welfare guardians and welfare powers of attorney.
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
OBJECTIVES OF THE POLICY
I.
To ensure a consistent and integrated approach across Scotland to DNA CPR decision
making and communication for all patients in all care settings in line with national good
practice guidance.
II.
To ensure that decisions regarding CPR are made according to:
- whether CPR could succeed
- the clinical needs of the patient
- the patient’s wishes and their judgement of the benefit provided by CPR
- current ethical principles
- legislation such as the Human Rights Act (1998) and Adults with Incapacity (Scotland) Act
(2000)
III.
To make DNA CPR decisions transparent and open to examination.
IV.
To ensure that a DNA CPR decision is communicated to all relevant healthcare professionals
and services involved in the patient’s care.
V.
To avoid inappropriate CPR attempts in all care settings.
VI.
To ensure staff, patients and their relevant others have appropriate information on making
advance decisions about CPR and that they understand the process.
VII. To clarify that patients and their relevant others will not be asked to decide about CPR when
it would clearly fail and therefore is not a treatment option, or when the circumstances of a
possible cardio-pulmonary arrest cannot be anticipated and therefore informed discussion
cannot take place.
VIII. To encourage and facilitate open, appropriate and realistic discussion with patients and their
relevant others about resuscitation issues.
IX.
To clarify the DNA CPR decision-making process for clinical staff caring for people who have
communication difficulties and other vulnerable groups.
Scope of the NHS Scotland DNA CPR Policy
This policy applies to all NHS Scotland Staff and the care of patients in all care settings within the
remit of NHS Scotland.
This policy is specifically about Cardio-pulmonary resuscitation (CPR). That is attempted
restoration of circulation and breathing in someone in whom one or both have suddenly and
unexpectedly stopped. It does not apply to other treatment and care, including procedures that
are sometimes loosely referred to as “resuscitation” such as rehydration, blood transfusion, IV
antibiotics etc.
The policy is applicable to babies and children (under 16 years) in the very rare instances where an
advance decision can be made that full CPR should not be attempted under any circumstances.
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
However for many babies and children (under 16 years) living with progressive, advanced and
incurable illness an advance decision about CPR is of less relevance than decisions about the
extent of measures to be taken in the event of a deterioration. In all but a very few situations,
therefore, this DNA CPR form will be inappropriate and some form of emergency care plan should
be in place.
It is implicit in this policy that generally recommended practice may be modified for the unusual
circumstances of a particular case. It is then of prime importance to record what was done, with
reasons why, in the case notes so that it can be justified afterwards.
CARDIO-PULMONARY RESUSCITATION: WHAT IT IS
AND WHAT IT IS NOT
CPR measures include external chest compression, artificial respiration and defibrillation. These
measures are normally instituted by local staff, and should precipitate an emergency call and other
active resuscitation measures. CPR is instituted immediately and in full following an unexpected
collapse if there is a realistic expectation of its being successful in achieving sustainable life.
The likely outcome of a successful CPR attempt is admission to an intensive care area or unit in
order that the restoration of circulation and breathing can be sustained and monitored.
CPR measures do not include analgesia, antibiotics, drugs for symptom control, feeding or
hydration (by any route), investigation and treatment of a reversible condition, seizure control,
suction, or treatment for choking. Comfort and treatment measures must be instituted after
assessment, consultation with patient and relevant others, and on the basis of clinical need,
irrespective of whether a DNA CPR form is present or not.
THE PRINCIPLES OF MAKING A DNA CPR DECISION
The circumstances of cardio-pulmonary arrest must be anticipated
If the circumstances of a cardio-pulmonary arrest cannot be anticipated, it is not possible to make
a DNA CPR decision that can have any validity in guiding the clinical team. In order to make an
informed decision about the likely outcome of CPR it is essential to be able to think through the
likely circumstance(s) in which it might happen for the patient. It is an unnecessary and cruel
burden to ask patients or relevant others about CPR when it seems unlikely that circumstances
would occur where the patient would require CPR. This should never prevent discussions about
resuscitation issues with the patient if they wish.
When CPR would not work it should not be offered as a treatment
option
In the situation where death is expected as an inevitable result of an underlying disease, and the
clinical team is as certain as they can be that CPR would fail (i.e. realistically not have a medically
successful outcome in terms of sustainable life), it should not be attempted. In this situation CPR is
not a treatment that can be offered and it is an unnecessary and cruel burden to ask patients and
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
relevant others to decide about CPR when it is not a treatment option. Although patients should
not be offered CPR where it is clear it will not be successful, open and honest communication is
essential to ensure the patient and relevant others have the opportunity to be made aware of the
patient’s condition.
Appropriate and sensitive communication and the provision of
information are an essential part of good patient care
The patient should be given as much information as they wish about their situation including
information about CPR and sensitive communication around dying and end of life issues. Relevant
others can be given such information if the patient agrees. It is not the professional’s responsibility
to decide how much information the patient should receive: their task is to find out how much the
patient wishes to know or can understand. If a patient does not have capacity for this decision,
then the clinical team must decide what would provide overall benefit for the patient, taking into
account the knowledge of relevant others about the patient’s previous wishes. Relatives should
never be placed in a position such that they feel they are making a DNA CPR decision unless they
are the legally appointed welfare attorney/proxy for the patient. Their role is to provide information
about the patient’s previously expressed wishes or what they believe the patient would wish in this
situation. The responsibility for making the DNA CPR decision lies with the most senior clinician
(doctor or nurse) who has clinical responsibility for that patient. Discussions about resuscitation
are sensitive and complex and should be undertaken by experienced healthcare staff. It is
recommended that staff have formal communication skills training in preparation for this clinical
responsibility.
These decisions can be difficult and cause considerable emotional distress. It is important that
patients are involved as far as possible in decisions regarding their care. However, the following
points are important to remember:
•
If a patient is aware that they are dying, and has not expressed a wish to discuss CPR, then a
DNA CPR order may be signed without further discussion with the patient. It is unnecessarily
burdensome to insist on discussing treatments that are futile and will not be offered, unless
there is obvious benefit for the patient in having such a discussion (such a benefit might be
having a DNA CPR form at home with the patient). It is obviously still important that the
patient is given ample opportunity to discuss their hopes and fears regarding their end-of-life
care.
•
Family/carers of a patient who has capacity should not be involved in resuscitation discussions
without that patient’s consent.
•
Family/carers should not be given the impression that they have decision making
responsibilities or rights, unless they have been legally appointed as the patient’s welfare
attorney and can act as the decision maker.
The timing and nature of discussions about resuscitation are a matter of judgement for the clinical
team. Such discussions can result in upset and even anger for patients and their families and are
often uncomfortable for healthcare staff, but anticipation of this should not prevent open and honest
communication. Where a DNA CPR decision is made on medical grounds because CPR will not
work opportunities to sensitively inform patients and relevant others should be actively sought
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
unless it is judged that the burden of such a discussion would outweigh the possible benefit for
the individual patient. These discussions are particularly important for patients who are at home
or being discharged home where CPR would be inappropriate because it is not wanted or would
not work. These patients and their relevant others must be aware of and understand the positive
purpose of the DNA CPR form for it to have any use in preventing a full emergency response by
ambulance crews and police and the possible benefit of such discussion should be clear for the
individual patient in such situations.
Any decision-making processes and/or discussions about resuscitation should be documented in
the medical or nursing notes.
Quality of life judgements should not be part of the decision-making
process for healthcare professionals
This policy adopts the view that clinical decisions should be based on immediate health needs,
and not on a professional’s opinion on quality of life. This is primarily because opinions on quality
of life made by health professionals are very subjective and often at variance with the views of the
patient and relevant others. Where CPR may be medically successful in achieving sustainable
life it is essential to know the patient’s fully informed views on the burdens and benefits for them
of this treatment and its likely outcome. Where a patient has capacity for this decision and it is
realistic to expect that CPR may achieve sustainable life the patient’s wishes about wanting or not
wanting CPR to be attempted are of paramount importance and must be respected.
Where no advance decision about CPR has been made there should be an
initial presumption in favour of providing CPR
When no explicit decision has been made about CPR before a cardio-pulmonary arrest occurs,
and the express wishes of the patient are unknown, it should be presumed that staff would attempt
to resuscitate the patient. However, although this should be the initial presumption there will be
some patients for whom attempting CPR is clearly inappropriate, for example a patient in the final
stages of a terminal illness where death is imminent and unavoidable and CPR would clearly not
be successful. Where CPR will clearly not work it should not be attempted and experienced
healthcare professionals who make this considered decision should be supported by their
colleagues.
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
THE DECISION-MAKING FRAMEWORK
The Framework below should be followed to allow you to make a
decision about cardio-pulmonary resuscitation. A shortened guidance
note is available on the second page of the Framework; however the
Framework should be viewed with the additional information provided in
Annex B of this policy.
THE DNA CPR FORM
The DNA CPR form is a means of communicating the decision that has
been made to those who may encounter the patient in the event of a
cardio-pulmonary arrest. A clinical team that knows the patient and is
certain of the background to the decision should not regard the decision
as invalid simply because a form has been incorrectly completed.
The presence or absence of a DNA CPR form may not override clinical
judgement about what will be of benefit to the patient in an emergency
(e.g. choking, anaphylaxis, sepsis etc).
If you are as certain as you can be that CPR would realistically NOT have a medically successful
outcome in terms of achieving sustainable life (following the Framework above) a DNA CPR form
should be completed and used to communicate this information to those involved in the patient’s
care. It is important that all relevant healthcare professional involved in the patient’s care are
aware that a DNA CPR decision has been made and a DNA CPR form exists. In order to facilitate
this, the original DNA CPR form should be immediately accessible wherever the patient is being
cared for.
Where a patient is moving to a different care setting a photocopy of the original form may be
retained for medical record audit purposes. A line should be drawn through the photocopy to
make it clear that it is not the valid DNA CPR form, before it is filed in the records.
Where a patient is at home, they and/or their relevant others must be aware of the DNA CPR form
for it to be of any use in an emergency situation. Where this conversation has not taken place the
form must not be sent home with the patient.
When a patient is being transferred to a different care setting it is necessary for the ambulance
crew involved to have the original DNA CPR form or a photocopy or written confirmation that the
DNA CPR form exists. The crew must also be informed of whether there has been discussion with
the patient and family about the DNA CPR form prior to the journey. This ensures compliance with
the Scottish Ambulance Service End of Life Care Plan (2008).
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
The Out of Hours Service must be made aware of the existence of the DNA CPR form when the
patient is being cared for in the community. They should also be informed where appropriate if this
decision is reversed.
Where a DNA CPR decision is being reversed the form should be clearly scored through with a
black pen and the word “reversed” written across it. The invalid form should then be filed in the
back of the medical notes.
REVIEWING THE DECISION
Each patient must be considered individually with the decision being reviewed as soon as is
practical when clinical responsibility for the patient changes and at clinically appropriate and
regular intervals. The time frame for review must be stated on initial completion of the DNA CPR
form and this may be on, for example, a six-monthly, one-monthly, fortnightly, weekly, daily or even
an hourly basis. Subsequent discussions are desirable on a periodic basis to allow for changes
in the patient’s circumstances or if treatment alternatives became available that may alter the
patient’s preference.
However, it is the responsibility of the junior medical and senior nursing staff to bring any change
in a patient’s condition to the attention of the senior doctor or nurse in charge as the DNA CPR
decision must be reviewed at any time the patient’s condition improves significantly.
WITHHOLDING OF RESUSCITATION
The appropriateness of CPR should always be considered on an individual patient basis. It is
acknowledged that there may be some healthcare units and care homes where a DNA CPR
decision is appropriate for the majority of patients but there is never a justification for blanket
policies to be in place. CPR should be withheld if either of the following is relevant:
A patient makes a competent advance refusal
•
Where CPR is not in accord with the recorded, sustained wishes of the patient who has
capacity for that decision.
•
Where CPR is not in accord with a valid applicable advance healthcare directive (living will).
A patient’s informed and competently made refusal which relates to the circumstances which
have arisen should be respected.
The treatment of CPR would not be of overall benefit for the patient
•
Where a patient’s condition indicates that effective CPR would not achieve sustainable life.
•
Where the patient judges that the benefits of successful CPR are likely to be outweighed by
the burdens of that treatment or of the sustainable life that is likely to be achieved.
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
RESPONSIBILITY FOR DECISION-MAKING:
PATIENTS AND THEIR RELATIVES/CARERS
A competent patient can:
make an advanced refusal of CPR
- even if CPR is deemed to be very likely to be successful.
- They do not have to give a reason for such refusal.
accept (consent to) CPR if offered.
- CPR must only be offered if it is realistically judged likely to be medically successful in
achieving sustainable life for that patient in the event of a cardio-respiratory arrest.
A patient who has capacity cannot:
Demand CPR if it is clinically judged that it would not be medically successful in
achieving sustainable life for that patient.
- Healthcare staff cannot be obliged to carry out interventions that they judge are not
indicated/ may be harmful.
- If agreement cannot be reached after sensitive and open discussion, a second opinion
should be accessed.
Where a patient lacks capacity for involvement in advance decisions and
has no legally appointed welfare attorney/proxy decision maker
- the responsibility for deciding if resuscitation is in the patient’s best interests lies with the
lead clinician with clinical responsibility for the patient.
- family/carers/next of kin do not have decision making rights or responsibilities in this
circumstance. Discussion with the family has the primary aim of trying to clarify the
patient’s views, prior to incapacity.
Where a patient lacks capacity for involvement in advance decisions and a
legally appointed welfare attorney/proxy decision maker has been
identified
The proxy decision maker can
- make an advance refusal of CPR for the patient.
- accept (consent to) CPR if offered (and realistically judged by the senior clinician to be
likely to achieve sustainable life for the patient).
The proxy decision maker cannot
- demand CPR if it is clear that CPR will not be successful in achieving sustainable life for
the patient.
- if agreement cannot be reached after sensitive discussion, a second opinion should
be accessed.
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
CHILDREN
The parent is the legal guardian for any child under 16 years of age. Where the treatment of CPR
may achieve sustainable life for the child in the event of a cardio-pulmonary arrest, the parent
must give his/her consent when a DNA CPR order is activated or rescinded. However, some
children of younger age, especially those with chronic illness, may be deemed competent to
express their own view with regard to withholding care or resuscitative measures. The views of
the parent(s), the child, close family members (where appropriate) and medical and nursing staff
should be sought before deciding to implement a DNA CPR order.
RESPONSIBILITY FOR DECISION-MAKING:
PROFESSIONAL
The overall responsibility for making an advance decision about CPR rests with the senior clinician
(doctor or nurse) who has clinical responsibility for the patient during that episode of care. This
will usually be the medical consultant (in General Hospitals) or the General Practitioner (in the
Community based Hospitals, or the patient’s home). However, it is also reasonable for other
grades of experienced medical staff and experienced senior nursing staff to take responsibility for
this decision provided that they accept that they have clinical responsibility for the patient during
that care episode. It is appropriate that the decision that CPR should not be attempted should be
made in consultation with other members of the care team including junior medical colleagues,
general practitioner and senior nursing staff. In exceptional circumstances more junior members
of medical staff may decide if CPR is appropriate; this decision should be confirmed by the senior
doctor in charge at the earliest opportunity. Junior doctors without full GMC license to practise (i.e.
Foundation Year 1) should not make this decision.
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ANNEX A
NHS Scotland Framework for Cardio-Pulmonary Resuscitation (CPR)
Decisions
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
ANNEX B
Supporting Information when making CPR decisions and completing a
DNA CPR Form
To be viewed with the NHS Scotland Framework for Cardio-Pulmonary Resuscitation (CPR)
Decisions and NHS Scotland DNA CPR form
Can the cardiac arrest or respiratory arrest be anticipated?
NO
DNA CPR decisions are only possible in advance where a patient is felt to be at risk of a cardiopulmonary arrest either as a sudden and acute event as a result of existing significant illness or
because they are identified as imminently dying.
If it is not possible to anticipate circumstances where cardio-pulmonary arrest might happen there
is no clinical DNA CPR decision to make.
•
Do not initiate discussion about CPR with the patient or relevant others.
•
The patient and relevant others should be informed that they can have a discussion, or
receive information, about any aspect of their treatment. If the patient wishes, this may include
information about CPR and its likely success in different circumstances.
•
Continue to communicate progress to the patient and relevant others if the patient agrees.
•
Review only when circumstances change.
•
In the event of an unexpected cardio-pulmonary arrest there should be a presumption that
CPR would be carried out.
•
No DNA CPR form should be completed.
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Can the cardiac arrest or respiratory arrest be anticipated?
YES
Are you certain as you can be that CPR would realistically have a
medically successful outcome in terms of achieving sustainable life for
that patient?
If the patient is not dying as a result of an irreversible condition and if the team is as
certain as it can be that CPR would realistically have a possibility of a medically successful
outcome the next decision is whether the patient has capacity to take part in this discussion
and fully comprehend the implications of the decision.
Patients with capacity are able to understand their situation and the consequences of their
decisions. Adults should be presumed to have capacity unless there is evidence to the contrary,
for example evidence that a patient is suffering from depression or is under the influence of others
would warrant a formal assessment of capacity. An assessment of capacity should relate to the
specific decision the patient is being asked to make and to their ability to fully comprehend their
situation and the implications of their decision.
Patients who are judged to lack the capacity to make decisions about their care should be
managed under the principles of the Adults with Incapacity (Scotland) Act (2000).
If the patient has capacity for this decision:
•
sensitive, honest and realistic discussion about CPR and its likely outcome should be
undertaken with the patient by an experienced member of the clinical team unless the patient
makes it clear they do not wish to have this discussion.
•
Continue to communicate progress to the patient and relevant others if the patient agrees.
If the patient does not have capacity for this decision:
•
a previously appointed legal welfare guardian/proxy should be asked to make the decision for
the patient in this situation with the help of sensitive and honest discussion with experienced
members of the clinical team.
•
Where no legal proxy has been appointed for the patient the clinical team should enquire
about the patient’s previously expressed wishes from the relevant others. The clinical team
have responsibility for making the most appropriate decision based on whether the benefits to
the patient offered by CPR outweigh the likely burdens/harm created by the treatment.
•
Continue to communicate progress to the relevant others.
Document this discussion in the medical and nursing notes detailing the circumstances that any
decision relates to and who was involved in the decision making process.
Complete DNA CPR form if appropriate.
Review regularly when clinically appropriate and if circumstances change for the patient.
In the event of a cardio-pulmonary arrest, act according to the patient’s previous wishes (or if the
patient was not competent, follow the decision made by the clinical team).
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
Can the cardiac arrest or respiratory arrest be anticipated?
YES
Are you as certain as you can be that CPR would realistically NOT have a
medically successful outcome?
If the patient is dying as a result of an irreversible condition, CPR is unlikely to be successful. If the
clinical team is as certain as it can be that CPR would not realistically have a medically successful
outcome it is inappropriate to offer it as a treatment option.
•
Allow a natural death in the event of a cardio-respiratory arrest.
•
Good palliative care should be in place to ensure a comfortable and peaceful time for the
patient with support for the relevant others.
•
Do not burden the patient or relevant others with having to decide about CPR when it is not a
treatment option.
•
Document the fact that CPR will not benefit the patient.
•
Complete DNA CPR form.
•
Ensure that patient has and understands as much information about their condition as they
want and need (the reasons why CPR will not work may be part of this information).
•
Where a patient is at home or is being discharged home they and/or their relevant others must
be aware of the DNA CPR form for it to be of any use in an emergency situation. The benefit
of having the form at home may be judged to outweigh the potential burden of the discussion
about CPR in the context of end of life issues. The opportunity for sensitive discussion about
this should be actively sought by experienced medical and nursing staff to allow the patient to
have a DNA CPR form at home with them if appropriate.
•
The judgement about when and how to discuss this without causing harm to the patient is a
matter for the patient’s clinical team to decide but should always be considered as part of
discharge planning for any patient with a DNA CPR form who is being discharged home from
hospital or hospice.
•
In the absence of a completed DNA CPR form, it is appropriate that the medical or experienced
nursing staff do not commence CPR as long as they remain certain that CPR will not work and
is therefore inappropriate for that patient.
•
Review regularly at clinically appropriate intervals (e.g. fortnightly). Review if medical
circumstances change and if medical responsibility for the patient changes (e.g. patient
discharged home from hospital).
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NHS SCOTLAND DNA CPR POLICY – DRAFT FOR CONSULTATION
MEDICAL PREDICTION OF THE OUTCOME OF
RESUSCITATION
Unfortunately many patients and their relevant others have unrealistic expectations of the success
of CPR and its consequences. Where CPR may be medically successful realistic and honest
explanations traumatic nature of the treatment and of the probability of survival to discharge can
significantly influence the resuscitation choices of patients.
Medical prediction of the outcome of resuscitation should be as realistic as possible and take into
account the clinical condition of the patient, the likely cause of the anticipated arrest and also the
environment within which the patient is being cared.
It is recommended that medical predictions be made on the likely outcome of a prolonged
resuscitation unless the patient is in a Coronary Care or Intensive Care setting.
A medical DNA CPR decision should be based on the clinical judgement that effective CPR will
not be medically successful in achieving sustainable breathing and circulation for the individual
patient rather than any judgement about the quality of the life that may be achieved.
This policy is adapted from the NHS Lothian Do Not Attempt Resuscitation Policy 2007, with
permission of the authors Spiller J, Murray C, Short S & Halliday C, by the National DNA CPR
working group 2009.
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DISCLAIMER
The NHS Scotland Do Not Attempt Cardio-Pulmonary Resuscitation (DNA CPR) Policy does not
provide the exhaustive detail required for individual personnel to be competent in making
decisions on resuscitation. The NHS Scotland Do Not Attempt Cardio-Pulmonary Resuscitation
(DNA CPR) Policy should be regarded as providing only one component of any recipient
organisation’s own comprehensive policy. Scottish Government uses reasonable endeavours to
ensure the accuracy and reliability of the NHS Scotland Do Not Attempt Cardio-Pulmonary
Resuscitation (DNA CPR) Policy but no guarantees are made that the information contained in
the NHS Scotland Do Not Attempt Cardio-Pulmonary Resuscitation (DNA CPR) Policy is
accurate, complete or current at any given time. Any information in the NHS Scotland Do Not
Attempt Cardio-Pulmonary Resuscitation (DNA CPR) Policy is issued as general information and
is not warranted by Scottish Government or any other health organisation, nor should it be taken
as advice. No responsibility can be accepted by Scottish Government or any other health
organisation for action or inaction as a result of information contained in the NHS Scotland Do
Not Attempt Cardio-Pulmonary Resuscitation (DNA CPR) Policy. Specific advice should be
sought in specific situations from a suitably qualified expert.
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APPENDIX 1: The DNA CPR Form
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APPENDIX II: The Decision-Making Framework
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APPENDIX III: Patient Information Leaflet
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This leaflet explains:
• what cardio-pulmonary resuscitation (CPR) is
• how you will know whether it is relevant to you
• how decisions about it are made.
This is a general booklet for all patients but it may also be useful to your relatives,
friends and carers. It may not answer all your questions about CPR, but it should help
you to think about the issue.
If you have any other questions, please talk to one of the health professionals caring for
you.
What is CPR?
Cardio-pulmonary arrest means that a person’s heart and breathing stop. When this
happens, it is sometimes possible to try to restart their heart and breathing with
emergency treatment called CPR.
CPR might include:
• repeatedly pushing down very firmly on the chest (“cardiac compressions”)
• using electric shocks to try to restart the heart (“defibrillation”)
• inflating the lungs through a mask over the nose and mouth or tube inserted
into the windpipe.
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What CPR is not
CPR has nothing to do with giving food, fluids, antibiotics, pain-relieving drugs, or other
treatment that may be needed for health and comfort. The need for these will depend
on your problems at the time. You can, of course, talk to your nurses and doctors
about the treatments you wish or do not wish to receive.
Is CPR tried on everybody whose heart and breathing stop?
When the heart and breathing stop unexpectedly, for example if a person has a serious
injury or heart attack, the healthcare team will try CPR if it might help, but a person’s
heart and breathing also stop working as part of the natural and expected process of
dying. If people are already very seriously ill and near the end of their life, there may be
no benefit in trying to revive them each time their heart and breathing stop. This is
particularly true when patients have other things wrong with them that mean they don’t
have much longer to live. In these cases where the clinical team is certain that CPR will
not work, it will not be attempted and natural death will be allowed to happen.
Am I likely to have a cardio-pulmonary arrest?
The health professionals caring for you are the best people to discuss the likelihood of
you having a cardiopulmonary arrest. People with the same symptoms do not
necessarily have the same disease and people respond to illnesses differently. It is
normal for health professionals and patients to plan what will happen in case the
patient has a cardio-pulmonary arrest. Somebody from the healthcare team caring for
you, probably the doctor or nurse in charge, will talk to you about:
• your illness
• what you can expect to happen
• what can be done to help you.
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What is the chance of CPR reviving me if I have a cardio-pulmonary
arrest?
The chance of CPR reviving you will depend on:
•
•
•
•
why your heart and breathing have stopped
any illnesses or medical problems you have (or have had in the past)
the overall condition of your health
the length of time passing before CPR can be started.
Attempted CPR is successful in restarting the heart and breathing in about 4 out of 10
patients. On average, 2 out of 10 patients survive long enough to leave hospital. The
figures are very much lower for patients with serious underlying conditions and for
people at home. It is important to remember that these only give a general picture
and not a definite picture of what you can expect. Everybody is different and the
healthcare team will explain what CPR could do for you.
Do people get back to normal after CPR?
Each person is different. A few patients make a full recovery, some recover but have
health problems but most attempts at CPR unfortunately do not restart their heart and
breathing despite the best efforts of everyone concerned. It depends on why their
heart and breathing stopped working and the patient’s general health. It also
depends on how quickly their heart and breathing can be restarted.
Patients who are revived are often still very unwell and need more treatment, usually in a
coronary care or intensive care unit. Some patients never get back the level of physical
or mental health they enjoyed before the cardio-pulmonary arrest. Some have brain
damage or go into a coma. Patients with many medical problems are very unlikely to
make a full recovery. The techniques used to restart the heart and breathing sometimes
cause side effects, such as bruising and occasionally fractured ribs and punctured
lungs.
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Does it matter how old I am or that I have a disability?
No. What is important is:
• your state of health
• your wishes.
Who will decide about CPR?
There are situations where doctors and nurses can be absolutely certain that CPR
would not work to restart someone’s heart and breathing. In these situations CPR is not
a treatment that can be offered and so the senior doctor or nurse responsible for the
care of the patient can document that CPR is not to be attempted.
You and your doctor or nurse can discuss whether CPR should be attempted if you
have a cardio-pulmonary arrest. The healthcare team looking after you will look at all
the medical issues, including whether CPR is likely to be able to restart your heart and
breathing if they stop. If it is likely that CPR would restart your heart and breathing, your
healthcare team will need to know whether you feel this would benefit you.
Sometimes restarting a person’s heart and breathing leaves them with a severe
physical or mental disability or dependent on artificial breathing (a ventilator) and you
may feel that this would not be a bearable situation. In this situation you are the only
person who can decide whether or not CPR would benefit you although you can
involve your close friends and family in the discussion if you wish.
Your healthcare team will be able to discuss with you how likely you would be to
completely recover from a CPR attempt in your particular situation.
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What if I don’t want to decide?
You don’t have to talk about CPR if you don’t want to, or you can put discussion off if you
feel you are being asked to decide too much too quickly. Your family, close friends and
carers might be able to help you make a decision you are comfortable with. Otherwise,
the senior doctor or nurse in charge of your care will decide whether or not CPR should
be attempted, taking account of things you have said. If you are under 16 your
parents can decide for you. Adults can appoint a ‘proxy’ to make decisions for them.
This can be done by contacting the Office of the Public Guardian or a solicitor. If you
have not formally chosen a proxy, the doctor or nurse in charge of your care will make
a decision about what is right for you.
Your family and friends are not allowed to decide for you. But it can be helpful for the
healthcare team to talk to them about your wishes. If there are people you do (or do
not) want to be asked about your care, you should let the healthcare team know.
What if my relative is the patient but is unable to understand discussions
about CPR?
Sometimes illnesses like dementia or conditions involving learning disability mean that
patients are unable to understand what CPR is about and cannot make a judgment
about whether it would be of benefit for them.
If there is no realistic possibility of CPR being medically successful for your relative the
senior doctor or nurse responsible for their care will document this to ensure that CPR is
not attempted and to allow a natural death that is as dignified and peaceful as
possible. The doctor or nurse will be happy to discuss this with you and answer any
questions you may have about this but there will be no decision for you to make.
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If there is any realistic possibility of CPR being medically successful for your relative a
decision must be made about whether this would be of benefit for them with regard to
the quality or length of life that would be likely to be gained by successful CPR. If you
have previously been legally appointed as your relative’s proxy or welfare guardian you
will be asked to make this decision on behalf of your relative. The doctor or nurses looking
after your relative will be able to help you with this complex decision if you wish by talking
through the issues and explaining what the reality of “successful” CPR would be for your
relative. If there is no legally appointed proxy the senior doctor or nurse who is
medically responsible for your relative will make the decision based on as much
information as possible from you and other family/carers about what the patient’s views
and wishes would have been.
I know that I don’t want anyone to try to resuscitate me. How can I
make sure they don’t?
If you don’t want CPR, you can refuse it and the healthcare team must follow your
wishes. You can make a living will (also called an ‘advance directive’) to put your wishes
in writing. If you have a living will, you must make sure that the healthcare team knows
about it and puts a copy of it in your records. You should also let people close to you
know so they can tell the healthcare team what you want if they are asked.
What if we haven’t decided and I have a cardio- pulmonary arrest?
If your heart and breathing should stop suddenly and no one has made a decision
about CPR, then the healthcare team looking after you at the time will attempt CPR
unless they are certain that it will not work.
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What if it is decided that CPR won’t be attempted?
The healthcare team will continue to give you the best possible care. The senior doctor
or nurse in charge of your care will make sure that you, the healthcare team, and the
friends and family that you want involved in the decision, know and understand the
decision, unless you don’t want to talk about it or unless the team feel that such a
discussion would be harmful to you. There will be a note in your health records that you
are ‘not for attempted cardio-pulmonary resuscitation’. This is sometimes called a ‘donot-attempt-cardio-pulmonary resuscitation’ or DNA CPR decision.
What about other treatment?
A DNA CPR order is about CPR only and you will receive all the other treatment you
need.
What if I want CPR to be attempted, but my doctor says it won’t work?
If it is certain that CPR would not be successful in restarting your heart or breathing in
the event of your death then it is not a treatment that can be offered as an option for
you. Experienced doctors and nurses will be able to sensitively explain why CPR will not
work for you if you do not understand this. You should be aware that this can be an
upsetting discussion to have with your healthcare team. It is common for people to
have very unrealistic expectations of what CPR might achieve and your doctor or nurse
can help to explain your own individual situation if you wish this.
Although nobody can insist on having treatment that will not work, no doctor would
refuse your wish for CPR if there was any real possibility of it being successful. If there is
doubt whether CPR might work for you,
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the healthcare team will arrange a second medical opinion if you would like one. If CPR
might restart your heart and breathing, but is likely to leave you severely ill or disabled,
your opinion about whether these chances are worth taking is very important. The
healthcare team must listen to your opinions and to the people close to you if you want
them involved in the discussion.
What if I am at home or being discharged home?
Many patients with serious illness who are facing death in the near future want to be
reassured that when it happens it will be peaceful, pain-free, dignified and, if possible, at
home in the company of their loved ones. Even if you have discussed this with your
family they may call 999 by mistake or because they feel they need urgent help for you.
If there is no DNA CPR form available and the ambulance crew finds that you are dying
or have died they have to respond with a full CPR attempt even if your family tell them
this is not what you wanted. This emergency response may also involve the police and
can be very traumatic and distressing for your family particularly if they know that your
wish was for a peaceful death at home.
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If you have decided that you do not wish CPR to be attempted or if your doctor is certain
that CPR would not work for you in the event of a cardiopulmonary arrest at home it is
possible for you to have a “Do Not Attempt Cardio-Pulmonary Resuscitation” (DNA
CPR) form at home with you. This can be a very upsetting discussion to have with your
healthcare team particularly if you have a serious illness but have not previously thought
about the possibility of dying suddenly. Unfortunately this discussion is very important if
you wish to avoid receiving inappropriate treatment from the emergency services
(ambulance crews and police) in the event of 999 being called when you are at home.
If you have a DNA CPR form at home the ambulance crews will ensure that you receive
appropriate treatment (such as comfort measures) and that your family get the
support that they need at this difficult time.
Your healthcare team may raise this issue with you but you can also ask them about it
at any point.
What if my situation changes?
The healthcare team will review decisions about CPR regularly and if your wishes or
condition change.
What if I change my mind?
You can change your mind at any time, and talk to any of the healthcare team caring for
you.
Can I see what’s written about me?
Yes, you can see what’s written about you. The healthcare team will make a note of
what you say about CPR and of any decisions that are made. You can ask the
healthcare team to show you your records and, if there is anything in them that you do
not understand, they will explain it to you. You also have a legal right to see and have
copies of your records.
Who else can I talk to about this?
If you would like a chance to talk to a member of staff from the local Department of
Spiritual Care, healthcare staff will be able to contact them for you.
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Independent Organisations
Age Concern Scotland
0845 833 0200
Aims are to ensure that older people in
Contact can be made
Scotland have their rights upheld, their
7 days a week, 7am-7pm
needs addressed, their voices heard and
choice and control over all aspects of www.ageconcernscotland.org.uk
Email: enquiries@acscot.org.uk
their lives.
Citizens Advice Scotland
Your local Citizens Advice Bureau can
offer advice to ensure that individuals do
not suffer through lack of knowledge of
their rights and responsibilities, or of the
services available to them.
Office of the Public Guardian
Offers advice on matters relating to
the Adults with Incapacity (Scotland) Act
2000
and
appointment of proxy
decision-makers.
The Independent Advice &
Support Service
Offers advice and assistance with
making a complaint on aspects of NHS
services.
Find the contact number
for your local Bureau in the
Telephone Directory
or on the
Citizens Advice Scotland
Website
www.cas.org.uk
01324 678300
Contact can be made
Mon-Fri, 9am-5pm
www.publicguardian-scotland.
gov.uk
0131 558 3681
Contact can be made
Mon-Fri, 9am-5pm
If you feel that you have not had the chance to have a proper discussion with the
healthcare team, or you are not happy with the discussions you have had, please ask a
member of staff for contact details of the local Complaints or Patient Liaison Officer.
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This information booklet has been adapted from the British Medical Association publication “Decisions about cardio-pulmonary resuscitation – model
information leaflet”, July 2002. The model information leaflet has been endorsed by Age Concern Scotland, Resuscitation Council (UK) and Royal
College of Nursing.
© Spiller, Murray, Short & Halliday, Lothian Health Board, 2007
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REFERENCES
Adults with Incapacity (Scotland) Act (2000). Edinburgh, HMSO.
BRITISH MEDICAL ASSOCIATION, (2000). The impact of the Human Rights Act 1998 on medical
decision making. London, BMA Books.
BRITISH MEDICAL ASSOCIATION, (2001). Withholding or withdrawing life-prolonging medical
treatment. 2nd ed. London, BMA Books.
BRITISH MEDICAL ASSOCIATION, (2007). Decisions Relating to Cardio-pulmonary
resuscitation, a joint statement from the British Medical Association, Resuscitation Council (UK)
and Royal College of Nursing. London: BMA.
COOPER, S et al (2006). A decade of in-hospital resuscitation: Outcomes and prediction of
survival? Resuscitation, 68: 231-237.
GENERAL MEDICAL COUNCIL, (2001). Good medical practice; Ch. 3 and 6. London, General
Medical Council.
GILL, R., (2001). Decisions relating to Cardio-pulmonary resuscitation: commentary 1- CPR and
the cost of autonomy. Journal of Medical Ethics, 27: 317-8.
Human Rights Act (1998). London, HMSO.
LUTTRELL, S., (2001). Decisions relating to Cardio-pulmonary resuscitation: commentary 2some concerns. Journal of Medical Ethics, 27: 319-20.
MENCAP, (2001). Considerations of ‘quality of life’ in cases of medical decision making for
individuals with severe learning disabilities. London, MENCAP.
REGNARD C & RANDALL F (2005). A Framework for making advance decisions on resuscitation.
Clinical Medicine, 5(4):354-360.
ROMANO-CRITCHLEY, G. SOMERVILLE, A., (2001). Professional guidelines on decisions
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SCOTTISH AMBULANCE SERVICE AND SCOTTISH PARTNERSHIP FOR PALLIATIVE CARE
End of Life Care Plan. August 2008.
SCOTTISH EXECUTIVE HEALTH DEPARTMENT, (2000). Resuscitation Policy. Edinburgh,
Scottish Executive Health Department. (HDL (2000) 22).
SPILLER, J., MURRAY, C., SHORT, S., HALLIDAY, C,. NHS Lothian Do Not Attempt
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THE SCOTTISH GOVERNMENT 2008. Living and Dying Well. A national action plan for palliative
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THORNS AR & ELLERSHAW JE (1999). A survey of nursing and medical staff views on the use
of Cardio-pulmonary resuscitation in the hospice. Palliative Medicine, 13: 225-232.
WATT, H., (2001). Decisions relating to Cardio-pulmonary resuscitation: commentary 3- degrading
lives? Journal of Medical Ethics, 27:321-3.
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