Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) - integrated adult policy: guidance

ANNEX B: Supporting Information when making CPR decisions and completing a DNACPR Form

To be viewed with the NHSScotland Framework for Cardiopulmonary Resuscitation ( CPR) Decisions and NHSScotland DNACPR form

Can the cardiac arrest or respiratory arrest be anticipated?

? NO

If it is not possible to anticipate circumstances where cardiopulmonary arrest might happen there is no clinical DNACPR 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 cardiopulmonary arrest there should be a presumption that CPR would be carried out unless it would clearly fail.
• No DNACPR form should be completed.
• Where a patient has strong views about treatments such as CPR that they would not wish to receive in certain future circumstances they should be supported to develop an advance healthcare directive.

Can the cardiac arrest or respiratory arrest be anticipated?

? YES

DNACPR decisions are 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. Where a cardiopulmonary arrest is not imminently expected it may still be reasonable to make an advance decision about CPR where a patient's death would not be unexpected due to advanced illness, significant frailty and/or co-morbidities.

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. 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:

• Where appropriate, 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 consent to or refuse treatment 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 DNACPR form if appropriate.

Review regularly when clinically appropriate and if circumstances change for the patient.

In the event of a cardiopulmonary arrest, act according to the patient's previous wishes (or if the patient lacked capacity, follow the decision made by the clinical team).

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 clinical team is as certain as it can be that CPR would fail 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 DNACPR form.

• Ensure that the patient has and understands as much information about their condition as they want and need (the reasons why CPR will fail 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 DNACPR 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 DNACPR 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 DNACPR form who is being discharged home from hospital or hospice.
• In the absence of a completed DNACPR form, it is appropriate that the medical or experienced nursing staff do not commence CPR as long as they remain certain that CPR will fail 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).

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 DNACPR working group 2010.