Transcript Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) Dr

Do Not Attempt CardioPulmonary Resuscitation
(DNACPR)
Dr Linda Wilson
Consultant in Palliative Medicine
Airedale/Manorlands
Both right - knowing
when to do which and
making it happen –
that’s our challenge!
If cardiac or respiratory arrest is an expected part
of the dying process and CPR will not be
successful, making and recording an advance
decision not to attempt CPR will help to ensure
that the patient dies in a dignified and peaceful
manner.
It may also help to ensure that the patient’s last
hours or days are spent in their preferred place of
care by, for example, avoiding emergency
admission from a community setting to hospital.
GMC ‘Treatment and Care Towards the End of Life’ 2010
This session:
 Background
 When/who
to discuss with
 How to record
 How to discuss- DVD
Useful Guidance
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2007: Joint guidance on DNACPR from UK
Resus. Council, BMA and RCN
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2007: Mental Capacity Act 2005 (MCA) Code of
Practice
2010: Treatment and care
towards the end of life:
good practice in decision
making. GMC
2010:NHS Bradford &
Airedale Joint Policy
Bottom line
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Resuscitation should be attempted in every
patient who wishes for this to happen and for
whom it has a reasonable chance of success
Cardiac arrest is the final event in all deaths,
inappropriate CPR may subject people to an
undignified death
It is crucial to identify those patients with
capacity who state clearly that they do not want
CPR to be attempted
Does CPR work?
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Many hospital studies but not standardised
Overall around 10-20% survive to leave
hospital
Pneumonia, hypotension, renal failure,
cancer, AIDS, sepsis, dementia, creatinine >
130 μmol/L, CVA, CCF all been associated
with a decreased likelihood of survival
Public estimates of survival in the region of
50%
Summary
Clinical experience, supported by the
evidence in the literature, would suggest
that CPR in patients with advanced,
progressive cancer (and other advanced
progressive conditions) who have poor
performance status, and irreversible
medical problems, can be classified as
physiologically futile according to any
definition.
Suzanne Kite THE LANCET Oncology Vol 3 October 2002
When to consider a DNACPR decision
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Patients with an advanced life
threatening illness if you would not be
surprised if they were to die within the
coming 12 months (?nursing homes)
As part of any advanced care planning
discussions
At a patients request
DNACPR decision making- 4
scenarios
1.
Futile
1.
2.
2.
Capacity
Lack Capacity
May work
1.
2.
Capacity
Lack Capacity
1. Futile with Capacity
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you are NOT OBLIGED to discuss it with
patients or their families, HOWEVER…….
You must carefully consider whether it is
necessary or appropriate to tell the patient that a
DNACPR decision has been made
You should not withhold information simply
because conveying it is difficult or uncomfortable
If you conclude that the patient does not wish to
know about or discuss a DNACPR decision, you
should seek their agreement to share with those
close to them, the information they may need to
know in order to support the patient’s treatment
and care
2. Futile Lack Capacity
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You should inform
any legal proxy and
others close to the
patient about the
DNACPR decision
and the reasons for it.
If you think CPR may be successful…
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If patient has capacity
 You should offer
opportunities to
discuss whether
CPR should be
attempted
Patient who lack capacity and for
whom CPR may work
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Do they have an ADRT?
Do they have a legal proxy?
Make a best interests decision in conjunction
with family
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their role is to advise you and the healthcare team
about the patient. You must not give them the
impression that it is their responsibility to decide.
IMCA if suitable family/others or legally
appointed proxy to consult
How to record
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The new form !
Process of transfer from one setting to
another:
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Review DNACPR decision prior to transfer
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Original form to be sent with patient
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Inform all relevant professionals (template) and
handover forms
Discussing CPR
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May happen naturally as part of a general
discussion
Ensure comfort and privacy; sit down next
to the patient.
Ask if family members or others should be
present.
Introduce the subject with a phrase such
as: I’d like to talk with you about possible
health care decisions in the future.
2. What does the patient
understand?
 An informed decision about DNR status is only
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possible if the patient has a clear understanding
of their illness and prognosis.
Ask an open-ended question to elicit patient
understanding about their current health
situation.
Consider starting with phrases such as: What do
you understand about your current health
situation? or What have the doctors told you
about your condition?
If the patient does not know/appreciate their
current status this is time to review that
information.
3. What does the patient expect?
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Ask the patient to consider the future.
What do you expect in the future? or What goals do you
have for the time you have left—what is important to
you?
Most patients with advanced, life limited disease
use this opening to voice their thoughts about
dying—typically mentioning comfort, family,
and home, as their goals of care.
If there is a sharp discontinuity between what
you expect and what the patient expects, this is
the time to clarify.
Summarise
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So what you’re saying is, you want to be as
comfortable as possible when the time comes
What you’ve said is, you want us to do everything
we can to fight, but when the time comes, you
want to die peacefully.
We have agreed that the goals of care are to keep
you comfortable and keep you at home
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We will continue maximal medical therapy
to meet your goals. However, if you die in
spite of everything, we won’t use CPR to
bring you back.
It sounds like we should move to a plan that
maximizes your comfort.
I will write an order in your medical and
nursing records that if you die, no attempt
to resuscitate you will be made, is this ok
with you?
Persistent requests for CPR—
Understanding Why?
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“Can you explain why you feel that way?”
Inaccurate information about CPR
Use information leaflet
Hopes, fears and guilt.
"This decision seems very hard for you."
"I want to give you the best medical care possible; I know
you still want CPR, can you tell me more about your
decision?"
Managing Persistent Requests for CPR
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Consider obtaining a second opinion
Don’t complete the form and return to the
discussion another time
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DVD
 Questions
/ Discussion