do not atttempt cardio pulmonary resuscitation (dnacpr) policy€¦ · web view1.8.2014 1...

Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) Policy

December 2014

Version 1

(Refer to back page for version control record)

IMPORTANT NOTICE: If the review date of this policy or procedure has expired staff should seek advice from their clinical lead or manager regarding the appropriate action to be taken.

Staff should refer to the POD for the most up to date information.

Version 1 – Final Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) Policy

CONTROL RECORD

Title Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) Policy

Purpose This policy will provide a framework for DNACPR decisions for all staff working within Nottingham City Care Partnership

Audience Nottingham CityCare Partnership, Nottingham City Clinical Commissioning Group, General Practitioners and Registered Nurses

Version 1 Version Date December 2014

Issue 2 Issue Date December 2014

Status Final Review Date December 2017

Author Gillian Whitworth and Dr Christina Sharkey

Development group

Unified Regional Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Principles Group, Nottingham City End of Life Care Group, End of Life Care Team,

Superseded Documents

Do Not Attempt Resuscitation Policy (2003)

Associated Documents

Verification of Death Policy for registered nurses,2012, Administration and supply of controlled drugs policy, 2012

Approved by Governance and Risk Group Date December 2014

Ratified by Governance and Risk Group Date December 2014

Distribution list All staff within Nottingham CityCare Partnership

Access Rights Nottingham CityCare Partnership

Impact Assessment

Impact on Terms and Conditions in relation to this Version

None

How do the changes affect staff This policy highlights the need to use the East Midlands Do Not Attempt Cardio Pulmonary Resuscitation Decision Form

How do the changes affect working practices There are no changes to working practices

This policy introduces the opportunity, in certain circumstances, for registered nurses band 6 and above to complete the East Midlands Do Not Attempt Cardio Pulmonary Resuscitation Decision Form.

Document Author: Gillian Whitworth, Clinical Nurse Specialist for End of Life Care, Dr Christina Sharkey, Macmillan GP FacilitatorDate of Issue: August 2014 of 23


Contents

Page

1 Introduction 4

2 Evidence Base 4

3 Purpose 5

4 Scope 5

5 Definitions 5

6 Responsibilities 7

7 Risk Management (Indications and Contra-Indications/ Hazards) 9

8 Equipment List 10

9 Process 11

10 Where a person lacks capacity to make a decision 14

11 Review and changes to the DNACPR decision 15

12 Situation where there is a lack of agreement 15

13 Cancellation of a DNACPR decision 16

14 Suspension of a DNACPR decision 16

15 Training 16

16 Interaction with Other Policies and Procedures 17

17 Equality & Diversity Statement 17

18 Monitoring & Review (of this policy) 17

19 Further Guidance 18

References 18

Further reading 19

Appendix 1 – DNACPR Form and Decision Making Framework 20

Appendix 2 – Information Sharing Checklist Record 22

Version History 23

Change Control Record 23



1.Introduction1.1. Survival following community Cardio Pulmonary Resuscitation (CPR) in adults varies according to

the rhythm. In an audit of resuscitation outcomes, of those patients who arrested with a shockable rhythm 42% were discharged alive. For those who were in non–shockable rhythms only 6% survived (Docherty 2002). It also varies from setting to setting. After a cardiorespiratory arrest in hospital, the chances of surviving to hospital discharge are at best 15 – 20% (Sandroni 2007) Research undertaken by Nolan et al (2007) which analysed survival outcomes for patients admitted to intensive care units in the UK following cardiac arrest showed “Where cardiac arrest occurs out of hospital, the survival rate is lower, at best 5-10%”.

1.2. Although CPR can be attempted on any person prior to death, there comes a time for some people when it is not in their best interest, it is against their wishes or would be a futile intervention. It may then be appropriate to consider a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decision to enable the person to die with dignity.

1.3. This policy is designed to ensure staff working within Nottingham CityCare Partnership (NCCP) have a consistent approach to DNACPR decisions in line with current national/regional guidance and best practice.

1.4. Staff involved in resuscitation decisions must understand and implement this policy. The content of this policy will be made readily available to patients, their families and carers. This policy should be read in conjunction with the Resuscitation Policy.

1.5. A Unified Principles for Adult Do Not Attempt Cardiopulmonary Resuscitation (2011) has been created regionally with representation from the NHS in the East Midlands with input by local Specialist Palliative Care Services, Resuscitation officers, Primary and Secondary care services and the East Midlands Ambulance Service (EMAS). This policy aims to implement regional guidance and principles for NCCP.

1.6. This Policy has been devised in line with current National Guidance ‘Decisions relating to Cardiopulmonary Resuscitation’, a joint statement from the British Medical Association (BMA), The Resuscitation Council (UK), The Royal College of Nursing (2007).

1.7. This policy also recognises the work of the Advance Decisions to Refuse Treatment Project Team that supports the implementation of the Mental Capacity Act (2005a) (information available at: www.adrt.nhs.uk).

1.8. This policy endorses the East Midlands DNACPR form, for the recording of the DNACPR decision. The reverse of the DNACPR form includes a decision making framework that supports the Health Care Professional when making a DNACPR decision.

This policy does not refer to other aspects of care that may be referred to as ‘Resuscitation’ such as the treatment of choking and anaphylaxis or analgesic and fluid administration.

2.Evidence Base 2.1. The Unified Principles for Adult Do Not Attempt Cardiopulmonary Resuscitation (2011) is evidence

based from national guidance:

The Resuscitation Council UK standards for recording ‘Do Not Attempt Resuscitation’ (DNAR) decisions (2009).

Decisions relating to Cardiopulmonary Resuscitation, A Joint Statement from the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing (2007).



The General Medical Council ‘Treatment and Care towards the End of Life: good practice in decision making’ (2010). This includes specific guidance for DNACPR decisions.

2.2. Staff are expected to understand how the Mental Capacity Act (2005) works in practice and the implications for each patient for whom a DNACPR decision has been made. As part of the essential training all staff within NCCP involved in direct patient care should attend the Consent to Treatment and the Mental Capacity Act training once which is available through workforce development.

2.3. Listed are elements of the Human Rights Act (1998) which are also relevant to DNACPR decisions:

The individual’s right to life (article 2).

To be free from inhuman or degrading treatment (article 3).

Respect for privacy and family life (article 8).

Freedom of expression, which includes the right to hold opinions and receive information (article 10).

To be free from discriminatory practices in respect to those rights (article14).

3.Purpose3.1 This policy will provide a framework to ensure that DNACPR decisions:

Are made following standard practice.

Provide benefits to patients and carers in respect to the wishes of the individual, where possible.

Reflect the best interest of the individual.

Do not cause undue burden to patient and families when involved in the decision making process.

3.2 The policy will ensure that DNACPR decisions refer only to CPR and not to any other aspect of the individual’s care or treatment options.

3.3 Advanced care planning, including decisions regarding CPR, is an important part of providing good quality care. Communication and the provision of information are essential components of quality care.

4.Scope 4.1. This policy applies to the care of all patients over the age of 18, having their care delivered by

NCCP healthcare professionals regardless of setting, and complies with the principles established by NHS East Midlands.

4.2. This policy applies to all health care professionals within NCCP, if appropriate to their role.

5.DefinitionsAdvance Decision to Refuse Treatment (ADRT): Is a decision by an individual to refuse a particular treatment in certain circumstances. A valid and applicable ADRT is legally binding for healthcare staff.

Cardiac Arrest (CA): Is the sudden cessation of mechanical cardiac activity, confirmed by the absence of a detectable pulse, unresponsiveness, and apnoea or agonal gasping respiration.



Cardio Pulmonary Resuscitation (CPR): Any intervention delivered with the intention of restarting the heart and breathing. This could involve:

Chest compressions and ventilations. Defibrillation. Administration of drugs.

Clinical staff: this refers to clinical staff involved in delivering care to patients and their carers.

Independent Mental Capacity Advocate (IMCA): An IMCA supports and represents a person who lacks capacity to make certain specific decisions, including those concerning serious medical treatment, at a specific time and who has no family or friends who are appropriate to represent them.

Lasting Power of Attorney: A lasting power of attorney is a legal document that lets an individual appoint someone they trust as an ‘attorney’ to make decisions on their behalf. It can be drawn up at any time while an individual has capacity to make that decision, but has no legal standing until it is registered with the Office of the Public Guardian. An individual can create two types of LPA.

1. Property and Affairs LPA: A Property and Affairs LPA allows an individual to choose someone to make decisions about how to spend money and the way their property and affairs are managed.

2. Personal Welfare LPA: A Personal Welfare LPA allows you an individual to choose someone to make decisions about their healthcare and welfare. This includes decisions to refuse or consent to treatment on their behalf and deciding where you they live. These decisions can only be taken on an individual’s behalf when the LPA is registered and the individual lacks the capacity to make the decisions. A LPA can only consent to or refuse life sustaining treatment on behalf of the individual if, when making the LPA, the individual has specifically stated in the LPA document that they want the attorney to have this authority.

Once the personal welfare LPA has been properly registered with the Office of Public Guardian the LPA can act, if they have been given that authority, once the individual has lost the capacity to make the specific decision in question.

The weight of previous statements or comments on the refusal of treatment made before the LPA was appointed will need to considered thoroughly. The original LPA documentation itself should be checked to see if the LPA has been given the right to consent to or refuse the treatment in question, has the LPA’s authority in any way been restricted or have terms been made that say previous decisions must be respected. If an attorney is expressly contraindicating previous known wishes of the patient, a safeguarding referral should be make with a view to possibly challenging the attorney in court.

Enduring Power of Attorney: Prior to the Medical Capacity Act 2005 people were able to create Enduring Powers of Attorney. These must be registered with the Office of Public Guardian where a person is losing or has lost capacity however they only cover property and finances and does not accord the same decision making power in this context as a health and welfare LPA.

In all cases it is important to view the original document itself to determine what kind of “power of attorney” is in place. For further information see https://www.gov.uk/power-of-attorney.

Mental Capacity Act (MCA 2005a): The Mental Capacity Act 2005 provides the legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for themselves, or who have capacity and want to make preparations for a time when they may lack capacity in the future. It sets out who can take decisions, in which situations and how they should go about this. The Act received royal assent on 5 th April 2005 and came in to force during 2007.


https://www.gov.uk/power-of-attorney


Mental Capacity: An individual over the age of 16 is presumed to have mental capacity to make decisions for themselves unless there is evidence to the contrary. A persons capacity must be assessed specifically in terms of their capacity to make a particular decision at the time it needs to be made. Everybody must be treated equally e.g. they cannot be judged on the basis of their age, or condition. It is important to take all possible steps to try to help people make a decision for themselves.

Assessing Capacity: The starting point must always be to assume that a person has the ability to make a specific decision.

Two-stage test of capacity: To help determine if a person lacks capacity to make particular decisions the Act sets out a two-stage test of capacity.

Stage 1: Does the person have an impairment of, or a disturbance in the functioning of their mind or brain ?Stage 1 requires proof that the person has an impairment of the mind or brain, or some sort of disturbance that affect the way their mind or brain works. If a person does not have such an impairment or disturbance of the mind or brain they will not lack capacity under the Act.

If a person meets the criteria of stage one then the person undertaking the assessment moves onto stage two.

Stage 2: Does the impairment or disturbance mean that the person is unable to make a specific decision when they need to ?Stage 2 Assessing the ability to make a specific decision:

Does the person have a general understanding of what decision they need to make and why they need to make it?

Does the person have a general understanding of the likely consequences of making, or not making, this decision?

Is the person able to understand, retain, use and weigh up the information relevant to this decision?

Can the person communicate their decision (by talking or using sign language or any other means). Would the services of a professional (such as a speech and language therapist) be helpful?

If the person cannot do any of the above points specific to the decision that needs to be made, then they will be treated as lacking capacity to make that decision. Then a best interest assessment will need to be made on the persons behalf specific to the decision, as described in section 10.

6.ResponsibilitiesWhen a person accesses any health services, s/he has a right to care that is provided by competent staff and is safe. This is the duty of care that is ensured through clinical governance and associated policy and guidance. This policy and its forms/appendices are relevant to all NCCP staff, if appropriate to their role. In order to fulfil its responsibilities the following personnel are responsible to ensure Nottingham CityCare Partnership meets its objectives.

A joint statement by the British Medical Association Resuscitation Council UK, and the Royal College of Nursing (2007) states:

‘Decisions about CPR are sensitive and complex and should be undertaken by experienced members of the healthcare team. Healthcare organisations should ensure that their clinical



staff have the training and maintain the knowledge and skills to undertake discussions and decision-making about CPR.’

Responsibility for decision making and CPR must always rest with the most senior clinician in charge of a patient’s care. In the primary care setting this is usually the patient’s GP. The Nursing and Midwifery Council (NMC) stated in May 2008

“In the majority of cases this will be a registered medical practitioner but that in some cases, a senior nurse with appropriate training may fulfil this role, subject to local discussion and agreement”

For appropriate roles and responsibilities for senior nurses see section 9.11.

6.1 The Chief Executive and the Board of Directors Bear overall responsibility for this Policy and shall carry this out by overview of significant risks via the Governance and Risk Committee and the provision of resources as appropriate to achieve:

Responsible for implementing and disseminating the policy to all clinical staff within their area of responsibility.

The governance responsibilities and compliance with this document.

Ensuring all appropriate senior registered nurses band 6 and above attend the mandatory training: CPR Decision Making - Principles to Practice Course.

6.2 Team Managers To ensure that all NCCP staff where relevant to their role have access to and awareness of

the updates to this policy via the POD (document management system).

The principles for DNACPR decisions are implemented within their team.

Staff understand issues relating CPR decisions.

To ensure that all Registered Nurses, band 6 and above, directly involved in end of life care attend the CPR Decision Making - Principles to Practice Course which can be booked directly through the end of life care team.

DNACPR forms, leaflets and patient information leaflets are available as required.

6.3 NCCP staff Registered nurses band 6 and above who are directly involved in providing end of life care

must access the NCCP CPR Decision Making – Principles to Practice Course (see section 15 training ) in order to have understanding of their responsibility pertaining to DNACPR decision making.

Are aware of their clinical and professional responsibilities regarding the act of DNACPR decision making.

Once a DNACPR decision has been made ensure that an original DNACPR form (can be printed in colour or in black and white) is placed in the front of the patient’s Community Nursing Blue Folder so it can be found in the patient’s home. The existence of and location of the form must also be recorded on the patient’s electronic notes as an alert on the SystmOne patient home page and in the patient journal. Following consent from the patient to share information, the decision can be accessed within the Nottinghamshire Electronic Palliative Care Coordination System ( EPACCS ).

Understand their role in discussion and supporting carers/family when involved in DNACPR decision making process.



Ensure they are aware of the existence of a DNACPR decision and the whereabouts of the form, either through sensitive communications with the individual and their relatives or directly from the healthcare professional handing over the patient’s care.

Check the validity of any decision when attending a patient’s home. The DNACPR form must be the original document and signed by the clinician directly responsible for supporting the patient and making the decision.

Notify other appropriate services/organisations of the DNACPR decision and record on DNACPR information sharing checklist record.

Participate in the audit process, including information regarding a DNACPR decision.

6.4 End of Life Care TeamOn behalf of NCCP the End of Life Care Team have the following responsibilities:

As the current author of this policy have responsibility to ensure any relevant updates are amended in a timely manner.

Will update the overall policy in the required timeframe.

Will support the audit process.

Will be responsible for the design and delivery of the CPR Decision Making – Principles to Practice course.

Will provide ongoing support and advice regarding the process regarding DNACPR decisions. For support please call the End of Life Care Team on 8834787.

7.Risk Management (Indications and Contra-Indications/ Hazards)

7.1 Resuscitation must be attempted in all cases of cardiac arrest, whenever there is a chance of survival. The exceptions to this are:

If a valid DNACPR decision has been made and the form completed / agreed by the most senior clinician responsible for the patients care.

If an Advance Decision to Refuse Treatment regarding Cardiopulmonary Resuscitation is in place and made known in line with the statutory requirements of the Mental Capacity Act 2005a (section 5).

Hypostasis (also known as post mortem staining) or Rigor Mortis is present.

7.2 The overall responsibility for a DNACPR decision rests with the most senior clinician responsible for the patients care. A DNACPR decision should be made only after the appropriate consultation with the patient and consideration of all relevant aspects of the patient’s condition, these include:

The likely clinical outcome of success, including the likelihood of restarting the patient’s heart and breathing, and the overall benefit achieved from a successful resuscitation are considered.

The patient’s known or ascertainable wishes.

The patient’s human rights, including the right to be free from degrading treatment.

Staff have a professional duty to report some deaths to the Coroner and should be guided by local practice as to the circumstances in which to do so (NCCP Verification of Death by Registered Nurses Policy and Procedure 2013). However, deaths should always be reported where the deceased died a violent, unnatural death or sudden unexpected death, the cause of death is unknown, or the deceased died while in



custody or otherwise in state detention. For more information see: Coroners, post-mortems and inquests: https://www.gov.uk/after-a-death/when-a-death-is-reported-to-a-coroner.

7.3 The senior clinician making a DNACPR decision is responsible for communicating the decision to colleagues within the same care setting once the decision has been made. It must be recorded on the regionally approved form (appendix 1) and full documentation of the discussion with the patient and the family recorded. This must include consideration of a patient’s mental capacity to make a decision regarding CPR. (Please see section 10 for guidance regarding action to take when a patient lacks the capacity to make a DNACPR decision).

7.4 The form must be shown to any service provider involved in the patient’s care with the consent of the patient or where considered to be in the best interest of the patient if they do not have capacity to consent to sharing of information. In the unlikely event where a person refuses to give consent to share the information regarding DNACPR status staff should explain that it is imperative that relevant clinical information is shared with those involved in the care . Advice should be sought from the patient’s GP and senior management if the patient continues to refuse to consent to share.

7.5 The Nottingham Emergency Medical Service (NEMS) will need to be informed of the decision by completing an NEMS Special Patient Note form stating that a DNACPR order is in place (this can only be completed online, http://nww.awv.nems.nhs.uk\AWA\login.aspx.

7.6 People close to patients often have the perception that they have the final say about whether CPR should be attempted. In England, Wales and Northern Ireland, no person is legally entitled to give consent to medical treatment on behalf of an adult who lacks decision making capacity unless that person has been granted Lasting Power of Attorney under the Mental Capacity Act (2005a). Doctors have authority to act in their patient’s best interest where consent is unavailable. Relatives and others close i.e. those engaged in caring for the patient or interested in their welfare., should be assured that their views on what the patient would want will be taken into account in decision making but they cannot insist on treatment or non-treatment.

7.7 At present there is no system in place to inform the East Midlands Ambulance Service (EMAS) of the existence of a DNACPR decision. The person supporting the completion of the decision must inform the family that they need to inform the EMAS service of its existence in the event of dialling 999. It is important that the attending crew is shown a copy of the original DNACPR form on arrival at the patient’s location for them to be able to follow the decision.

7.8 Ambulance transfer: ambulance crews must be shown the original DNACPR form. The original DNACPR form that travels with the patient will act as instruction to ambulance staff.

7.9 Non ambulance transfer: other organisations transferring patients between departments, other healthcare settings and home should be informed of, and abide by, the DNACPR decision. This instruction should be documented on SystmOne.

Note: original DNACPR form to stay with the patient in the Blue Folder. Duplicate copies can be made for the patient’s healthcare records and for legal and audit purposes. Only the original is a valid document as duplicated versions may have been superseded.

8.Equipment List 8.1 DNACPR Form.

8.2 Patient leaflet about DNACPR

8.3 Information sharing Checklist

9.Process


https://www.gov.uk/after-a-death/when-a-death-is-reported-to-a-coroner


9.1 For the majority of people receiving care in hospital, social care or community setting, the likelihood of cardiopulmonary arrest (cessation of breathing and heartbeat) is small depending on the person’s condition; therefore, DNACPR discussions should not be discussed routinely unless raised by the individual. However there are circumstances where early discussions about CPR could be an important part of their own care planning e.g. patients identified with a life limiting illness.

9.2 In the event of a staff member finding a person dead and there is no CPR decision or an Advance Decision to Refuse Treatment (ADRT) to refuse CPR, staff must rapidly assess the case as to whether it is appropriate to commence CPR. If the decision is unclear CPR must be commenced immediately. Consideration of the following will help to form a decision. It must be stressed that professional judgement must be exercised and fully described in the patient record:

What is the likely expected outcome of undertaking CPR?

Is the undertaking of CPR contravening the Human Rights Act (1998) where the practice could be inhuman and degrading if futile?

Providing the staff member has demonstrated and documented a rational process in decision-making, NCCP will support the member of staff if this decision is challenged.

9.3 British Medical Association/ Royal College of Nursing/ Resuscitation Council UK guidelines consider it appropriate for a DNACPR decision to be made in the following circumstances:

Where the individual’s condition indicate that effective CPR is unlikely to be successful?

When CPR is likely to be followed by a length and quality of life not acceptable to the individual in their own opinion.

Where CPR is not in accord with the recorded, sustained wishes of the individual who is deemed mentally competent or who has a valid applicable ADRT.

9.4 The healthcare professional completing the DNACPR form will vary according to circumstances. In the primary care setting this would usually be the General Practitioner. However in specific circumstances this may be a registered nurse band 6 or above according to the requirements as stated as in sections 9.12 & 15.

9.5 When considering making an advance CPR decision with an individual it is important to consider the following:

Is Cardiac Arrest (CA) a clear possibility for this individual? If not, it may not be necessary to go further.

If CA is a clear possibility for the individual and CPR may restart heart. Would it be followed by a length and quality of life, in the patient’s judgement that would be acceptable to the person? Does the patient have the capacity to make these decisions about CPR? While no patient, regardless of capacity, can insist on treatment that is not clinically indicated, where a patient with capacity to make the decision refuses treatment including CPR, this must be respected. If the patient lacks capacity to make that decision, then this must be recorded and the appropriate best interest decision made and recorded.

Where the individual has an irreversible condition where death is the likely outcome and CPR is unlikely to be successful the individual or their family (where appropriate) must be consulted save where inappropriate to do so (see 9.6) and their views taken into account. Once a DNACPR decision has been made, they should be sensitively informed of this. For the full decision-making guidance please refer to the decision making framework in appendix 1.

9.6 Consider the following in CPR decisions and discussions.



The fact that discussion about DNACPR may merely distress the patient is not sufficient reason for not discussing it with the patient. The clinician has a duty to consult the patient in relation to CPR unless he or she thinks that the patient will be distressed by being consulted and that this might cause the patient harm . Where a DNACPR discussion has not taken place e.g.where the clinician considers the discussion is likely to cause serious harm to their physical or mental well being or the individual has indicated a clear desire to avoid such discussions. The details of the discussion or a justification for not having a discussion, must be clearly documented in their healthcare records.

In this situation consent should be sought to discuss the matter with those closest to the patient i.e. those engaged in caring for the patient or interested in their welfare.

9.7 If a DNACPR decision is made, this must be clearly documented within the patient’s healthcare records. Information regarding the background to the decision, the reasons for the decision, those involved in the decision and a full explanation of the process must be recorded in the patient’s healthcare records/care plan.

In instances when CA has been identified as a risk for a specific individual and it is judged that CPR might re-start the heart and breathing. It is important that discussions about the likely benefits and burdens of CPR are held with the individual, or with appropriate individuals for those who lack capacity to make the decision themselves. Individuals do have the right to refuse to have these discussions.

Once the decision has been made, it must be recorded on the DNACPR form (appendix 1, section 3) documenting the discussion with the patient and or their family. For a DNACPR form to be valid, all sections must be completed. Failure to do this invalidates the form.

Permission should be sought from the patient to share information with those close to the patient i.e. those engaged in caring for the patient or interested in their welfare.

Where the patient lacks capacity to make the decision themselves, having undertaken the appropriate formal assessment, consider whether it is in the patient’s best interests to share the DNACPR decision with relevant others.

The DNACPR information leaflet must be made available to individuals and their relatives or carers. NCCP have endorsed the NHS East Midland information leaflet ‘Your guide to decision about cardiopulmonary resuscitation (CPR)’, which can be found at www.emas.nhs.uk under the end of life decision tab. This should be documented in the patient’s healthcare record. It is the responsibility of the individual organisation to ensure that different formats and languages can be made available where appropriate.

9.8 The original form will stay with the patient, located as follows:

The original form, once completed, must be placed in the front of the community nursing and rehabilitation notes (Community Nursing Blue Folder) and left in a prominent place in the patients home.

GP surgeries should ensure that the DNACPR decision is recorded in the individual’s electronic patient record ‘problem list’ using the appropriate Read Code.

All registered nurses who are involved in the DNACPR decision must ensure that the decision is documented on SystmOne and the record should be shared with the multidisciplinary team.

The person making a DNACPR decision is responsible for communicating the decision to other colleagues within the same care setting and other appropriate services/organisations.

9.9 The person in charge of discharge or transfer of care is responsible for communicating the decision to all other care providers involved and this should be recorded in the information sharing checklist record. The original document must stay with the patient and should be placed at the front of the patients ‘Community Nursing Blue Folder’. Where there is no Community Nursing Blue Folder in the care setting, the DNACPR form should be left in a prominent place that is easily accessible and this must be communicated to all care providers. Following consent from the patient to share


http://www.emas.nhs.uk/


information, the decision can be accessed within the Nottinghamshire Electronic Palliative Care Coordination System.

9.10 If the individual has the mental capacity to make decisions about how clinical information is shared, their agreement must always be sought before sharing this with family and friends. Refusal by an individual with capacity to allow information to be disclosed to family or friends must be respected. Where individuals lack capacity and their views on involving family and friends are not known, staff may disclose confidential information to people close to them, i.e. those engaged in caring for the patient or interested in their welfare where this is necessary to discuss the individual’s care and it is not contrary to their best interest.

9.11 Where there is disagreement about a decision not to attempt CPR because it will not be successful, a second opinion should be offered. The second opinion could be another GP, consultant or senior clinical registrar.

9.12 Registered Nurse completing a DNACPR form:

9.12.1 Within NCCP a Senior Registered Nurse band 6 and above may have CPR discussions with patients and undertake the completion of the form if the protocol below is adhered to and the nurse feels competent to do so (see Section 15).

The nurse may originate the DNACPR form prior to consultation with the patient’s senior clinician (usually GP) if all of the following criteria are met:

The nurse must have completed the NCCP CPR Decision Making: Principles to Practice Course.

The patient has been identified by the patient’s GP as being in the final days of life.

The patient has been commenced on an individualised end of life care plan for the dying patient.

The patient is aware and in agreement with the decision. Where the patient lacks the capacity to make the decision then a best interest decision is made on behalf of the patient.

The nurse should seek permission to share the decision with those close to the patient. However if the patient declines consent to share the information, the nurse must speak to the GP prior to leaving the form in the home.

Nurses signing the form should record their NMC number in section 1. This form is now valid and complete and can be acted upon. As an extra safeguard countersignature of the original form by the most senior clinician involved in their care (usually GP) should be sought at the earliest opportunity. The original document should be placed in the front of the Community Nursing Blue Folder or left in a prominent place in the patient’s home, the decision must be entered onto SystmOne as per record keeping policy and then a duplicate can be scanned onto SystmOne.

9.12.2 For a patient who has not been identified by the most senior clinician (usually GP) as being in the final days of life and has not been commenced on an individualised end of life care plan for the dying patient, conversations around advance care planning can take place between the nurse and the patient if the patient is willing to engage in these discussions e.g. CPR decisions.

If the patient expresses the wish not to have CPR the nurse should discuss this with the most senior clinician (usually GP) prior to form completion.

If the GP agrees the nurse could complete the DNACPR form including their NMC number in section 1 and leave it in the patient’s home. This form is now valid and complete and can be



acted upon . As an extra safeguard countersignature of the original form by the most senior clinician involved in their care (usually GP) should be sought at the earliest opportunity.

The GP may wish to arrange to see the patient themselves to discuss further before the nurse completes and leaves the DNACPR form in the patient’s home.

The nurse should seek permission to share the decision with those close to the patient. However if the patient declines consent to share the information, the nurse must speak to the GP prior to leaving the form in the home.

Review the decision as necessary in conjunction with the GP (see section 11).

9.13 Out of Hours Care with no DNACPR decision in place:

In the event that the patient’s condition has rapidly deteriorated out of hours and there is no DNACPR decision in place, and an urgent CPR decision needs to be made. E.g. Patient is on the end of life care pathway but not on an individualised end of life care plan for the dying patient and the pace of deterioration was not anticipated, the nurse must seek advice from the GP out of hours service (NEMS). The principles in 9.5 and 9.6 above must be followed as regard communication with patient and/or family.

If the decision to place the patient on an individualised end of life care plan for the dying patient has already been commenced “in - hours” and death is expected and this may happen out of hours then the nurse should follow the process as point 9.12.1.

Written information about resuscitation policies must be included in the general literature, provided to patients within health care establishments. Such information will be made readily available to all patients and to people close to the patient including relatives and partners. i.e. those engaged in caring for the patient or interested in their welfare. Patient information regarding DNACPR decision making will also be on the CityCare website for patients to access.

9.14 If English is not the first language of the patient; such discussions should take place in the patient’s first language using an impartial interpreter i.e. not a family member or friend. It is not acceptable to utilise significant others for such interpretation and discussion. If an interpreter is used, their name and designation should be clearly documented. Staff should follow the NCCP interpreting and translation guidance which can be accessed via the POD.

10 . Where a person lacks capacity to make a decision10.1 Section 4 of the Mental Capacity Act Code of Practice (2005b) outlines the process of decision

making in what is believed to be the best interest of a person who does not have the capacity to make a particular decision at a specific time i.e. a patient who lacks capacity to make a decision about CPR at the relevant time based on the individual’s known wishes, preferences, beliefs and values among other things.

10.2 A DNACPR decision should be made for an individual who does not have capacity to make a CPR decision at that relevant time, by a GP or a senior nurse meeting the criteria in 9.12, only if the decision is believed to be in their best interest as defined by the MCA. There must be a clear record of the decision making process. Any decision regarding CPR must be made on a non-discriminatory basis and assumptions should not be made on the basis of a person’s age, appearance, disability, condition or behaviour. A best interest decision about life sustaining treatment, cannot be motivated by a desire to bring about death as this is an explicit provision of the MCA (s4 (5)).

10.3 A blanket policy to deny particular groups of patients CPR is unethical and unlawful.

10.4 Where possible, professionals should seek to establish the person’s wishes, preferences, beliefs and values considering any previous advance statements or ADRT. Consult with those closest to



the person i.e. those engaged in caring for the person or interested in their welfare and/or the person with Lasting Power of Attorney (LPA) with the authority to make these decisions, if appropriate an Independent Mental Capacity Advocate (IMCA.). Other members of the health or care team should be consulted before making a DNACPR decision. If the patient lacks capacity to make a decision but is able to provide input that contribution, will weigh very heavily in any best interest decision.

GPs who have made this decision, should tell the people closest to the individual lacking capacity i.e. those engaged in caring for the patient or interested in their welfare if they reach a DNACPR decision and explain the reasons to them.

The MCA recognises that in emergency circumstances it may not be possible to instruct an IMCA to ascertain the patients best interests in an event of Cardiac Arrest.

If there is a dispute as to a patient’s best interest when CPR is to be withheld or withdrawn then the patient or those close to them, i.e. those engaged in caring for the patient or interested in their welfare should be offered a second opinion e.g. another GP, consultant or specialist registrar.

In the relatively rare circumstances where the patient or those close to them i.e. those engaged in caring for the patient or interested in their welfare continue to fundamentally disagree with the clinical team, legal advice should be sought and the courts can be asked to intervene where there is time to do so. The Head of Health Safety, Fire and Security and Head of Patient Safety must be notified in these circumstances.

It is the responsibility of the health care professional to supply information at an appropriate level, and engage others in supporting the person to understand it, regardless of capacity or any disability. Subsequent clinical interventions should include discussions about the patient’s understanding of the resuscitation decision. It is a fundamental principle of the MCA that someone should not be treated as lacking capacity for a particular decision until everything appropriate has been done to empower them to understand the relevant information MCA s1(3).

10.5 Documenting the assessment of a persons capacity using a two-stage test and the steps taken to make a best interest decision must be recorded in detail in the person’s record.

11. Review and changes to the DNACPR decision11.1 The frequency of review should be determined by the care at the time of the initial decision.

11.2 The DNACPR must be reviewed when there is a change in care setting by the senior clinician in charge for the transfer of care.

11.3 It is important to note that the person’s ability to participate in decision-making may fluctuate with changes in their clinical condition. Therefore, when a DNACPR decision is reviewed, staff must consider whether the person can contribute to the decision-making process each time. It is not usually necessary to discuss CPR with the person each time the decision is reviewed, if they were involved in the initial decision. Where a person has previously been informed of a decision and it subsequently changes, they should be consulted and informed of any change and the reason for it.

12. Situations where there is lack of agreement12.1 A person with mental capacity has a right to refuse any treatment from a doctor or nurse, even if

that refusal results in death. Any treatment carried out against their wishes could result in criminal charges.

Where appropriate, individuals should be encouraged to consider their wishes in relation to any Advance Decision to Refuse Treatment (ADRT).



Should the person refuse CPR, this should be clearly documented in the medical and nursing notes after an informed discussion with the individual and their relatives (if applicable).

A verbal refusal of CPR should not be ignored, it should be documented and does need to be taken into account when making a best interest decision for a person lacking capacity to make this decision.

Individuals might insist on CPR being undertaken even if the clinical evidence suggests that it will not succeed. Sensitive discussion with the person should aim to secure their understanding and acceptance of the DNACPR decision. Although individuals do not have a right to demand that doctors carry out treatment against their clinical judgement, the person’s wishes to receive treatment should be respected if possible. Where disputes remain, it may be appropriate to consider the opportunity for the patient to obtain a second opinion.

12.2 Where the clinical decision is seriously challenged and agreement cannot be reached, legal advice may be indicated. This should very rarely be necessary.

13. Cancellation of a DNACPR DecisionIn some circumstances, a decision may be made to cancel or revoke the DNACPR decision. If the decision is cancelled, the DNACPR form should be crossed through with two diagonal lines in black ball-point ink and the word ‘CANCELLED’ written clearly between them, dated and signed by the healthcare professional making this decision. It is the responsibility of the healthcare professional cancelling the DNACPR decision to record this on SystmOne.

Upon cancellation it is the responsibility of the clinician to update the relevant agencies as per the original DNACPR information sharing check list .and ensure that the Electronic Palliative Care Coordination System template is updated.

14. Suspension of DNACPR Decision14.1 In some circumstances, there are reversible causes of a CA. These are either pre-planned or acute

care, and the individual should receive treatment, unless non intervention in these circumstances has been specified.

14.2 Some procedures could precipitate a CA, for example, induction of anaesthesia, cardiac catheterisation, pacemaker insertion or surgical operations. Under these circumstances, the DNACPR decision should be reviewed prior to procedure and a decision made as to whether the DNACPR decision should be suspended. Discussion with key people, including the person if appropriate, will need to take place.

14.3 The DNACPR decision should refer specifically to the patients condition and outline the conditions for a CA (appendix One). For an acute injury or emergency situation where the person suffers an acute, unforeseen, but immediately life-threatening situation, such as anaphylaxis or choking, CPR may be appropriate in this instance even if a DNACPR decision is in place.

15. TrainingFor registered nurses band 6 and above who are interested in becoming involved in supporting patients through CPR discussions and the completion of DNACPR decision forms it is mandatory to complete the NCCP competency based training course “CPR Decision Making - Principles to Practice Course “ to support this practice.

The training will be facilitated by the End of Life Care Team.



This training will be essential for any registered nurses band 6 and above who are interested in becoming involved in supporting patients through CPR discussion and the completion of DNACPR forms.

The training course usually consists of six hours face to face in one working day.

The course will be advertised and accessed via the End of Life Care Team.

Upon completion of the course and any subsequent refresher training, the nurse will be required to complete a self-declaration of competence to practice supported decision making and completion of the DNACPR form. This form will then be noted on the individuals personal development and training profile.

The best practice guidance will be issued to every nurse on completion of the training.

The End of Life Care Team will monitor and evaluate the training and undertake audits to ensure that training and practices follow the Best Practice guide.

A register of staff trained complete DNACPR Decision forms will be held by the End of Life Care Team and forward to the Workforce Development team to be recorded on the Electronic Staff Record.

Three yearly refresher courses are mandatory for all (CityCare) clinicians making a DNACPR decision. These courses will be available upon request from the End of Life Care Team, for support or any queries on information and access to the training contact the End of Life Care team on 0115 8834787.

16. Interaction with Other Policies and ProceduresResuscitation Policy

Equality & Diversity Policy

MCA guidance 2005

MCA guide for people who work in health and social care

Interpretation and Translation Guidance

Record Keeping Policy

17. Equality & Diversity StatementThe Organisation will not tolerate the less favourable treatment of anyone on the grounds of their age, disability, gender, marital status, being pregnant or on maternity leave, race/ethnicity, religion or belief, sexual orientation, responsibility for dependents, trade union or political activities, or any other reason which cannot be shown to be justified (As referred in Section 6.1 of Equality and Diversity Policy May 2012).

18. Monitoring and Review (of this policy)18.1 The monitoring of compliance of this policy is the responsibility of all appropriate NCCP staff involved

in DNACPR decision making. Ensure that regular auditing is undertaken and that updates to this policy and the DNACPR form are undertaken and followed.

18.2 The monitoring of competencies to undertake this process is the responsibility of the individual professionals who are involved DNACPR decisions.This should be monitored by their managers as part of regular management supervision and during the Personal review and development (PRD) and personal development plan (PDP) process.


http://documents.nottinghamcitycare.nhs.uk/Documents/Human%20Resources/Equality%20and%20Diversity%20Policy.doc

http://documents.nottinghamcitycare.nhs.uk/Documents/Governance/Resuscitation%20Policy.doc


18.3 This document will be reviewed every two years or where there are changes to the legal framework.

18.4 The number of DNACPR decisions performed by CityCare staff will be audited annually by the End of Life Care Team through the palliative index card audit.

18.5 Any incident reported regarding DNACPR could result in a serious incident review or require a Root Cause Analysis (RCA) report and action plan. All patient safety incidents are monitored by the Patient Safety and Infection Prevention and Control Group monthly all RCAs are monitored at the same committee until all identified actions have been completed.

19. Further GuidanceIf you have any concerns or issues with the contents of this policy or have difficulty understanding how this policy relates to you and/or your role, please contact:

End of Life Care Team

Newbrook House

Alfreton Road

Nottingham

NG7 5LR

Tel 0115 8834787

ReferencesAdvance Decisions to Refuse Treatment: a guide for health and social care professionals. (2010)London: Department of Health http://www.endoflifecare.nhs.uk/assets/downloads/pubs_Advance_decisions_to_refuse_guide.pdf

Directgov: Public services all in one place. Managing your affairs and lasting power of attorney: https://www.gov.uk/power-of-attorney Last updated: 5 April 2013.

Decisions relating to Cardiopulmonary Resuscitation, A Joint Statement from the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing (2007)

General Medical Council (2010). Treatment and care towards the end of life: good practice in decision making. http://www.gmc-uk.org/End_of_life.pdf_32486688.pdf

Human Rights Act. (1998) London: Crown Copyright. http://www.legislation.gov.uk/ukpga/1998/42/contents

Mental Capacity Act. (2005a) London: Crown Copyright. http://www.legislation.gov.uk/ukpga/2005/9/contents

Mental Capacity Act (2005b) Code of Practice http://webarchive.nationalarchives.gov.uk/+/http:/www.justice.gov.uk/docs/mca-cp.pdf

Nolan J, Laver S, Welch C, Harrison D, Gupta V, Rowan K. Outcome following admission to UKintensive care units after cardiac arrest: a secondary analysis of the ICNARC Case MixProgramme Database. Anaesthesia ( 2007).

Resuscitation Council (UK) (2007) Decisions relating to cardiopulmonary resuscitation; a


http://webarchive.nationalarchives.gov.uk/+/http:/www.justice.gov.uk/docs/mca-cp.pdf

http://www.legislation.gov.uk/ukpga/2005/9/contents

http://www.legislation.gov.uk/ukpga/1998/42/contents

http://www.gmc-uk.org/End_of_life.pdf_32486688.pdf

https://www.gov.uk/power-of-attorney

http://www.endoflifecare.nhs.uk/assets/downloads/pubs_Advance_decisions_to_refuse_guide.pdf


joint statement from the British Medical Association, the Resuscitation Council (UK) andThe Royal College of Nursing. RC (UK) http://www.resus.org.uk/pages/dnar.pdf

Resuscitation Council (UK) (2009) Recommended standards for recording "Do not attempt resuscitation" (DNAR) decisions. http://www.resus.org.uk/pages/DNARrstd.htm

Regional representation of the NHS in the East Midlands December (2011) Unified Principles for Adult Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). Available at: http://www.emas.nhs.uk/contact/care-decisions/ under the tab East Midlands Unified DNACPR Principles

Royal College of Physicians (2009) Advance Care Planning. London: Royal College ofPhysicians http://www.rcplondon.ac.uk/pubs/contents/9c95f6ea-c57e-4db8-bd98-fc12ba31c8fe.pdf

Sandroni C, Nolan J, Cavallaro F, Anotelli M, In – Hospital cardiac arrest : incidence, prognosis and possible measures to improve survival , Intensive care Med 2007 ; 33 : 237 245.

Further Reading British Medical Association (2000). Access to health records by patients. London: BMA, 2000.

Coroners Act 1988 London: Crown Copyright.Coroners Act 1988 (c. 13) [Accessed 12/10/2009]http://www.opsi.gov.uk/acts/acts1988/ukpga_19880013_en_1

Department of Health (2001). Good practice in consent: achieving the NHS Plan commitment to patient-centred consent practice. www.dh.gov.uk

Joint Working Party between the National Council for Hospice and Specialist Palliative Care Services and the Ethics Committee of the Association for Palliative Medicine of Great Britain and Ireland. Ethical Decision-Making in Palliative Care: Cardiopulmonary Resuscitation (CPR) for people who are terminally ill. London: National Council for Hospice and Palliative Care Services, August 1997 (available at the Council’s website: www.hospice-spc-council.org.uk)

Next Stage Review (NSR) Group for End of Life Care in Nottinghamshire (2008) Nottinghamshire End of Life Care Pathway for All Diagnoses. Nottingham: NHS Nottinghamshire County, NHS Nottingham City, NHS Bassetlaw, and Local Authorities.

NHS End of Life Care Programme & the National Council for Palliative Care (2008)

Nottingham CityCare Community Liverpool Care Pathway : Version 12 (2009). Available at: http://documents.nottinghamcitycare.nhs.uk/Documents/End of Life Care/Nottingham CityCare Community Liverpool Care Pathway.doc

For general guidance on the impact of the Act on health care decisions, see British Medical Association. The impact of the Human Rights Act 1998 on medical decision-making. London: BMA, October 2000.

For more detailed guidance on decision making for children and young people see British MedicalAssociation. Consent, rights and choices in health care for children and young people. London: BMJ Books, 2001.


http://documents.nottinghamcitycare.nhs.uk/Documents/End%20of%20Life%20Care/Nottingham%20CityCare%20Community%20Liverpool%20Care%20Pathway.doc%20%20%20%20

http://documents.nottinghamcitycare.nhs.uk/Documents/End%20of%20Life%20Care/Nottingham%20CityCare%20Community%20Liverpool%20Care%20Pathway.doc%20%20%20%20

http://documents.nottinghamcitycare.nhs.uk/Documents/End%20of%20Life%20Care/Nottingham%20CityCare%20Community%20Liverpool%20Care%20Pathway.doc

http://www.hospice-spc-council.org.uk/

http://www.dh.gov.uk/

http://www.opsi.gov.uk/acts/acts1988/ukpga_19880013_en_1

http://www.emas.nhs.uk/contact/care-decisions/

http://www.resus.org.uk/pages/DNARrstd.htm

http://www.resus.org.uk/pages/dnar.pdf


Appendix 1: DNACPR Form



Appendix 2: DNACPR Decision

Information Sharing Checklist Record (to be stored with original DNACPR form)

Service

DNACPR Decision Recorded

Cancellation of DNACPR Decision

Date Method of Communication

Date Method of Communication

GP Surgery

Community and Rehabilitation Team

Out of Hours Service

Ambulance service

Secondary Care Services

Day care Services



Other (please specify)

Version History

Version Date Status Comment

1 29.10.2014 Reviewed and revised after consultation Governance and Risk and with CityCare solicitors

1.2 9.12 2014 Reviewed at Governance and Risk

Change Control Record

Date Version Section Changes made

1.8.2014 1 Re-written to include changes Mental Capacity Act 2005 and guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing (Oct 2014).
