The NHS ScotlandThe NHS Scotland Integrated DNACPR policy Integrated DNACPR policy

Dr Juliet SpillerDr Juliet SpillerConsultant in Palliative MedicineConsultant in Palliative Medicine

Marie Curie Hospice EdinburghMarie Curie Hospice Edinburgh

Aim of CPR – achieve sustainable lifeAim of CPR – achieve sustainable life CPR = total opposite of traditional idea of a CPR = total opposite of traditional idea of a

“good death” (peaceful, dignified, comfortable, “good death” (peaceful, dignified, comfortable, family presence etc)family presence etc)

What is a DNACPR decision?What is a DNACPR decision?– CPR is not to be CPR is not to be attemptedattempted when patient dies when patient dies

CPR won’t achieve sustainable life (Clinical)CPR won’t achieve sustainable life (Clinical) The burden of CPR Rx and likely outcome is such that The burden of CPR Rx and likely outcome is such that the the

patientpatient doesn’t want CPR attempted (overall benefit) doesn’t want CPR attempted (overall benefit)

– Protection for patients from aggressive, undignified, Protection for patients from aggressive, undignified, unnatural death – unnatural death – notnot a possible Rx being withheld a possible Rx being withheld

What is a DNACPR form?What is a DNACPR form?– Communication tool for that decisionCommunication tool for that decision

Why do people get so upset about Why do people get so upset about DNACPR orders?DNACPR orders?

Common misunderstandingsCommon misunderstandings– ““Not for CPR” means not for anythingNot for CPR” means not for anything

““being left to die”being left to die” ““being written off”being written off”

– CPR is nearly always successfulCPR is nearly always successful TV/media survival = 64%!TV/media survival = 64%!

– Successful CPR has no harmful effectsSuccessful CPR has no harmful effects Wake up smiling and have a cup of teaWake up smiling and have a cup of tea

Jean – 78yrs old with moderately severe dementia, Jean – 78yrs old with moderately severe dementia, emphysema, diabetes and osteoporosisemphysema, diabetes and osteoporosis

- Admitted to care home 2yrs ago following the death of her - Admitted to care home 2yrs ago following the death of her husband and an unsettled 2 months living with her only husband and an unsettled 2 months living with her only daughter.daughter.

- Gradual functional and cognitive decline, worsening eyesight. - Gradual functional and cognitive decline, worsening eyesight.

- Very unsettled by 2 recent hospital admissions for treatment - Very unsettled by 2 recent hospital admissions for treatment of chest infectionsof chest infections

- Sudden collapse on a Friday evening while staff were helping - Sudden collapse on a Friday evening while staff were helping her off the toilet – acutely breathless and distressedher off the toilet – acutely breathless and distressed

- 999 call. No pulse by the time paramedics arrived. CPR - 999 call. No pulse by the time paramedics arrived. CPR attempted. PLE after 20 mins (and rib fractures)attempted. PLE after 20 mins (and rib fractures)

- Police arrived, LUCS GP called but unable to provide death - Police arrived, LUCS GP called but unable to provide death certificatecertificate

- Jean’s body removed to police mortuary until Monday when - Jean’s body removed to police mortuary until Monday when own GP provided death certificateown GP provided death certificate

May 2006May 2006 NHS Lothian implementation of UK’s first fully NHS Lothian implementation of UK’s first fully integrated DNAR policyintegrated DNAR policy– DNAR form – all healthcare settings, home, care homes, DNAR form – all healthcare settings, home, care homes,

ambulance crews, policeambulance crews, police– Decision-making frameworkDecision-making framework– Patient info bookletPatient info booklet

Revised 2007Revised 2007 – Policy shared with individuals from SHBs and English SHAs Policy shared with individuals from SHBs and English SHAs

and national organisations (BMA, GMC, Marie Curie Cancer and national organisations (BMA, GMC, Marie Curie Cancer Care, Macmillan OoH Group, National Council for Palliative Care, Macmillan OoH Group, National Council for Palliative Care, Scottish Partnership for Palliative Care) Care, Scottish Partnership for Palliative Care)

Aug 2008Aug 2008 Living and Dying Well action point (SAS End Living and Dying Well action point (SAS End of Life Care Plan)of Life Care Plan)

Jan 2009Jan 2009 Public Audit Committee request for national Public Audit Committee request for national consistent DNAR policyconsistent DNAR policy

NHS Scotland DNACPR policy NHS Scotland DNACPR policy Consensus by national steering groupConsensus by national steering group

– Single NHS Scotland policy & documentationSingle NHS Scotland policy & documentation

– ““DNACPR” rather than DNARDNACPR” rather than DNAR

Emphasising best practice in CPR Emphasising best practice in CPR decision-making (nothing new)decision-making (nothing new)

Providing framework for improved Providing framework for improved communication of DNACPR decisions communication of DNACPR decisions (new)(new)

Boards to implement by October 1stBoards to implement by October 1st

NHS Scotland DNACPR policy NHS Scotland DNACPR policy

Does not make clinical Does not make clinical decision-making easydecision-making easy

Does not make the Does not make the communication issues communication issues easyeasy

…………that’s just part of the that’s just part of the job!job!

How does this apply to care homes? How does this apply to care homes?

Requirement to have a policy about resuscitation Requirement to have a policy about resuscitation decisions already exists (blanket policy of non-decisions already exists (blanket policy of non-resuscitation is unlawful and unethical)resuscitation is unlawful and unethical)

An opportunity to engage with a Scotland-wide An opportunity to engage with a Scotland-wide initiativeinitiative

Easy link with existing communication systems Easy link with existing communication systems (eg OOH special notes / ePCS)(eg OOH special notes / ePCS)

Immediately recognisable to GPs, OOH services, Immediately recognisable to GPs, OOH services, SAS, police who may attend residents in the homeSAS, police who may attend residents in the home

Transferable to acute hospitalsTransferable to acute hospitals Patients may be discharged to you with these Patients may be discharged to you with these

formsforms

• Consistent communication tool (Decision process and discussions should still be clearly documented in notes)

• Must be immediately accessible

• No form does not automatically mean CPR must be attempted

•Only refers to CPR

How does this benefit residents and How does this benefit residents and their families? their families?

Reassurance that a treatment that will not Reassurance that a treatment that will not work, or that is not wanted, will not be work, or that is not wanted, will not be attempted.attempted.

Reassurance that death will be as natural, Reassurance that death will be as natural, dignified and peaceful as is possible even dignified and peaceful as is possible even if the death is suddenif the death is sudden

……………………BUTBUT……….DNACPR should not be ……….DNACPR should not be addressed in isolationaddressed in isolation

A good idea applied in the wrong

way….can become a bad idea!

Anticipatory Care Plans - core info.Anticipatory Care Plans - core info. Diagnosis. Welfare attorney/guardianDiagnosis. Welfare attorney/guardian

What can be anticipated for this person and how What can be anticipated for this person and how should that be managed?should that be managed?

Views and advance decisions about escalation of Views and advance decisions about escalation of treatment / place of care / place of deathtreatment / place of care / place of death

ITUITUHDUHDU

DNACPRDNACPRIV treatmentIV treatment

oral treatmentoral treatmentcomfort measures comfort measures

onlyonly

DNACPR in practice in Care homesDNACPR in practice in Care homes Part of anticipatory care planning – evolving and Part of anticipatory care planning – evolving and

individualised processindividualised process

Not about asking all residents if they want Not about asking all residents if they want resuscitatedresuscitated

Not about asking family to make a decision Not about asking family to make a decision (where CPR can be offered) unless they are (where CPR can be offered) unless they are legally appointed healthcare proxylegally appointed healthcare proxy

Clarify prior to transfer / admission if possibleClarify prior to transfer / admission if possible

Ensure all staff are aware DNACPR decision is Ensure all staff are aware DNACPR decision is only about CPR – any deterioration should be only about CPR – any deterioration should be assessed and managed appropriatelyassessed and managed appropriately

DNACPR in practice in Care homesDNACPR in practice in Care homes Where CPR clearly won’t work it can’t be Where CPR clearly won’t work it can’t be

offered – clinical decisionoffered – clinical decision Responsibility for decision – most senior Responsibility for decision – most senior

clinician with clinical responsibility for the clinician with clinical responsibility for the patient = GP / Senior nurse (d/w your GPs)patient = GP / Senior nurse (d/w your GPs)

Good practice to sensitively inform resident as Good practice to sensitively inform resident as part of ACP informationpart of ACP information

Where patient lacks capacity relatives should Where patient lacks capacity relatives should be informed of ACP information including be informed of ACP information including DNACPRDNACPR

Such discussions can be nurse / carer led (d/w Such discussions can be nurse / carer led (d/w your GPs)your GPs)

What if they get upset….?

Continued reluctance for DNACPR discussions

To discuss or not to discuss….?To discuss or not to discuss….? Timing – it’s Timing – it’s not just about CPR outcomenot just about CPR outcome

– Awareness of palliative phase of illnessAwareness of palliative phase of illness– Any indication of willingness for advance care Any indication of willingness for advance care

planning conversations?planning conversations?– Is talking about death something this patient can Is talking about death something this patient can

get their head around without get their head around without harmfulharmful distress at distress at the moment (or ever)?the moment (or ever)?

““Benefit vs. burden” balance of the discussionBenefit vs. burden” balance of the discussion– Different for patients at homeDifferent for patients at home– For some patients it will never be the right thingFor some patients it will never be the right thing– For many patients it is a relief and a reassuranceFor many patients it is a relief and a reassurance

Informing relativesInforming relatives

Need patient consent to discuss with relativesNeed patient consent to discuss with relatives– But needn’t always be explicitly for DNACPRBut needn’t always be explicitly for DNACPR

Where the patient lacks capacity “you should Where the patient lacks capacity “you should inform any legal proxy and others close to the inform any legal proxy and others close to the patient of the DNACPR decision and the patient of the DNACPR decision and the reasons behind it”reasons behind it”

GMC 2010GMC 2010

TrainingTraining

Information and educational resource Information and educational resource available on websiteavailable on website

www.scotland.gov.uk/dnacprwww.scotland.gov.uk/dnacpr

Awareness sessions run locally – contact Awareness sessions run locally – contact resuscitation departmentresuscitation department

Communication aspects of DNACPR discussionsCommunication aspects of DNACPR discussions– DVD available via websiteDVD available via website– Facilitated sessions may be organised through local Facilitated sessions may be organised through local

palliative care servicepalliative care service

Key questions for groupsKey questions for groups How can we engage with the GPs that support the How can we engage with the GPs that support the

care home to ensure best practice around DNACPR care home to ensure best practice around DNACPR decision-making?decision-making?

How can we engage with the acute hospitals to How can we engage with the acute hospitals to ensure best practice on admission to and discharge ensure best practice on admission to and discharge from acute hospitals to care homes?from acute hospitals to care homes?

How can we empower staff to understand and How can we empower staff to understand and address DNACPR decision-making in the context of address DNACPR decision-making in the context of anticipatory care plans as standard best practice for anticipatory care plans as standard best practice for residents?residents?