Cardiopulmonary resuscitation decisions - integrated adult policy: guidance

Annex A: Supporting Information when making CPR decisions and completing a DNACPR Form

To be viewed with the NHSScotland Policy 2016 Decision-making Framework for Cardiopulmonary Resuscitation ( CPR) Decisions and NHSScotland DNACPR form

Is cardiac or respiratory arrest a clear possibility for the patient?

NO

If it is not possible to anticipate circumstances where cardiopulmonary arrest might happen there is no advance decision to make about CPR.

• 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 is unequivocally clear at the time that CPR would not work).
• No DNACPR form should be completed.
• When 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.

Is cardiac or respiratory arrest a clear possibility for the patient?

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.

Is there a realistic chance that CPR could be successful?

YES

If the team is as certain as it can be that CPR would realistically have a possibility of a medically successful outcome (achieve sustainable life) the next decision is whether the patient has capacity to take part in this discussion and fully comprehend the implications of the decision to consent to or refuse CPR being given.

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. All reasonable support to aid decision making should be offered.

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 in the context of goals of care 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:

• Where it is practicable and appropriate, a previously appointed legal welfare attorney/guardian must be involved in the decision-making process for the patient with the help of sensitive and honest discussion with experienced members of the clinical team.
• When no legal proxy has been appointed for the patient, the clinical team should make reasonable efforts to understand the person's own preferences, and 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. Those close to the patient must be enabled to make their views about this known as part of the decision-making discussions where practicable and appropriate.
• Continue to communicate progress to the relevant others.

Document this discussion in the relevant clinical notes detailing the circumstances that any decision relates to and who was involved in the decision-making process.

Complete DNACPR form if appropriate.

Review if and 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).

Is there a realistic chance that CPR could be successful?

NO

If the clinical team is as certain as it can be that CPR would not work it is inappropriate to offer it as a treatment option.

• Allow a natural death in the event of a cardio-respiratory arrest.
• Any unexpected sudden acute deterioration must be assessed and managed as appropriate for that patient's clinical situation and goals of care.
• Good palliative care should be in place to ensure a comfortable and peaceful time for the patient with support for the relevant others.
• There should be a presumption in favour of informing the patient as part of a sensitive conversation about goals of care and available treatment options. Where the patient lacks capacity those close to them must be sensitively informed of the decision before it is documented where that is practicable and appropriate. Patients and their relevant others should be aware that they are not being asked to make a decision about CPR as it is not a treatment option, but consider whether to offer a second opinion if there is ongoing disagreement.
• Complete the DNACPR form and document the fact that CPR will not work for the patient and the reasons for this decision.
• Clearly document all discussions with the patient, relevant others and colleagues or a clear explanation of why such conversations have not taken place.
• When 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. If it has previously been judged potentially harmful to the patient to make them aware of the DNACPR decision this must be reviewed prior to discharge. The benefit of having the form at home may be judged to now outweigh the potential harm 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 suitably experienced medical and nursing staff to allow the patient to have a DNACPR form at home with them if appropriate. This information should be communicated to the senior clinician responsible for the patient in the community setting so that this information can be communicated by the Key Information Summary.
• The judgement about when and how to discuss this without causing physical or psychological harm to the patient is a matter for the patient's clinical team to decide but should always be re-considered as part of discharge planning for any patient with a DNACPR form who is being discharged home or to a care home from hospital or hospice.
• In the absence of a completed DNACPR form, it is appropriate that the medical or experienced nursing staff who know the patient do not commence CPR as long as they remain certain that CPR will fail and is therefore inappropriate for that patient.
• Review at individualised clinically appropriate intervals unless it is certain that the DNACPR decision will remain appropriate until the patient's death. Review if medical circumstances change and if medical responsibility for the patient changes (e.g. patient discharged home from hospital).

The original policy (2010) was 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. The policy has undergone a Light Touch Review in 2015/16 by the National DNACPR Policy Review group. Membership of the review group and the original working group can be found on the Scottish Government website http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/peolc/DNACPR.