Professional Documents
Culture Documents
Objectives
Key points of the policy Framework for resuscitation decisions The DNACPR form Patient Information Leaflet
The Policy:
Based on integrated DNAR policy implemented by NHS Lothian In line with revised Joint statement on CPR decisions by BMA/RCN/RC(UK) 2007 and GMC guidance (2010) Fully integrated between Primary and secondary care services Supported By Scottish Ambulance Service Recommended in Living and Dying Well the Scottish Government Action Plan for Palliative and End of Life Care Requested by Public Audit Committee
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Hospital issues:
Increased movement of staff and patients between hospitals Patients being looked after by increased numbers of different staff (shifts, teams, hospital at night etc.) DNACPR documentation deferred due to belief that all patients must be asked about DNACPR decisions
Community issues:
Existence of DNACPR order needs to be communicated to GP, DN, care home staff and OOH on discharge
Existence of DNACPR order at home needs to be communicated to hospital/hospice team on admission GPs often unsure when to sign DNACPR orders
For DNs, Marie Curie nurses and other experienced palliative care nurses a default of attempting CPR in the absence of a DNACPR form is impractical
Ambulance issues:
Existence of DNACPR form needs to be communicated to ambulance personnel Mechanism needed for informing emergency and OOH service about DNACPR order
Clear instructions are needed about what to do in the event of death in transit Who to contact Where to take the patient
Picture of framework
Available in all areas Quick reference of the policy Extra guidance notes on the reverse
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Yes
decision to have DNACPR order rests with competent patient Sensitive exploration of patients wishes if appropriate Set in context of patients illness, end of life care wishes 12 and likely outcome of successful CPR
Explanation of successful CPR should be realistic - remember patient and family perception of it is not!
Will it work and how will I be if it works? Patients/relatives yes definitely with a cup of tea afterwards to help recover to full health (TV survival to hospital discharge = 63%) Doctors/Nurses possibly (Drs overestimate prognosis by factor of 5 when discussing with patients/relatives) Reality probably not / definitely not (survival to hospital discharge 13-14%)
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If CPR might realistically be successful but patient lacks capacity to make a decision
A decision about what will be of overall benefit for the patient must be made by the clinical team or legally appointed welfare guardian A benefit vs burden judgement must be made about CPR and its likely outcome for that patient Relatives must not be made to feel that they are making the decision but can offer opinions about what the patient would have wanted.
YES:
Are you as certain as you can be that CPR could realistically not have a successful outcome ( in terms of medically sustainable life)
Yes
decision to have DNACPR order rests with senior clinician (Dr or nurse) responsible for the patient Actively seek opportunities to sensitively make patient aware of this as part of information about illness and prognosis DNACPR form can be completed without discussing 15 with patient
In certain settings an experienced nurse may be the most senior responsible clinician decision for the patient (eg nurse consultants or senior clinical nurse specialists). Such a decision may be recorded on a DNACPR form and signed by the experienced nurse.
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Communication tool (Decision should still be clearly documented in notes) Clearer instructions
Review when clinical responsibility changes and at individualised clinically appropriate intervals Complete Ambulance Crew Instructions before transfer
If the form is going home with the patient it must be the original
Inform GP / community nurses / OOH before discharge home If form not going to patients home but patient still DNACPR send to GP
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When no DNACPR decision has been made and the patient arrests:
However, it is unlikely to be considered reasonable to resuscitate a patient who is clearly in the terminal phase of illness
Experienced medical or nursing staff are therefore not obliged to initiate resuscitation in a patient whos death is clearly expected
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Used to improve patient and relative awareness and assist discussions Worth reading if you dont know where to start with DNACPR discussions
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Remember: DNACPR Orders only refer to cardiopulmonary resuscitation, not to any other treatments.
Unexpected deterioration should always be assessed and managed appropriately irrespective of DNACPR status
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Any Questions ?
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