Getting “DNACPR” right

Ms Catherine Baldock Head of ResuscitationDr Rob Simpson Chair Resuscitation CommitteeDr Alistair Brookes Clinical Lead Resuscitation

Objectives

• Outline the implications of the Tracey Case Law

• Discuss issues around DNACPR process

• Highlight the evidence

• Discuss future developments

DNACPR

“Allowing a natural and dignified death at the end of life”

Tracey Case Law

Case deals with obligation on clinicians to communicate their decision as part of advance care planning.

Janet Tracey had capacity and expressed a wish to be consulted.

The Court of Appeal in Tracey did not deal specifically with patients who lack capacity.

It was not about the clinical decision that had been made.

Tracey Case Law

• COMMUNICATION!

• There were communication failures at all levels:

– Operational communication• Poor discussion

• Poorly recorded

– Tactical communication• Trust level policy

• A lack of information about DNACPR that was accessible to patients

Tracey Case Law

• Strategic communication

– Public (mis)perception about

CPR• What it entails

• What it will (not) achieve

– Historically widely used

– Media coverage focuses on the successes of CPR and negatives of DNACPR

• Footballer survives for 45mins

• Holby City or Casualty

What Tracey is about: the actualdecision

• “Since a DNACPR decision is one which will potentially deprive the patient of a life-saving treatment, there should be a presumption in favour of patient involvement.”

• A decision of this type impacting on how the patient will end her/his life engages Article 8 ECHR.

• DNACPR decisions are made in advance so there is an opportunity to discuss.

What Tracey is about: the actual decision

• Two step process on patient involvement:– The clinician:

• Should only decide NOT to discuss if likely to cause physical or psychological harm (more than distress)

• Should not exclude patient because CPR futile

– The patient is free to decline to be involved or informed:

• Family should be involved if patient agrees (or if incapable of involvement)

What should we do about it?

•Communicate

•Record

•Familiarity with national

guidance

•Robust DNACPR policy

•Accessible to patients

•DNACPR leaflets

The Incapacitated Patient

Capacity Assessment – Mental Capacity Act 2005.

Lack capacity (decision specific).

Check for valid and applicable advance decisions.

Best Interests Decision – may be straightforward in some cases.

Section 4 MCA 2005 – best interests checklist.

Legal obligation to consult where it is practical and appropriate to do so.

The Incapacitated Patient –the process

Consulting or informing – involvement

Consulting to assist clinicians to make best interest decision – remember: relatives cannot demand treatment on patient’s behalf Family/friends/carers

Independent Mental Capacity Advocate (“IMCA”) – serious medical treatment

Attorneys with Lasting Powers

What hasn’t changed

DNACPR is a clinical decision.

Clinicians are not required to provide treatment that is a) clinically inappropriate or b) is not in best interests of the patient.

Genuine emergencies – follow usual clinical decision making process.

Not required to provide inappropriate CPR to ‘buy time’ to speak to relatives.

Presumption that patients (or their relatives) should be involved in discussion where time permits.

Standard for communication

• DNACPR decisions should be discussed with the patient (assuming they have capacity).

• Discussions should be recorded on the DNACPR form/patient case notes.

• If the patient lacks capacity the reasons for this should be documented.

• DNACPR decision should be discussed with the family to try to ascertain the patient’s view regarding CPR.

• If the family are not available at the time the DNACPR decision is made the plan/proposal for speaking to the family should be recorded. This should include timescales.

Standard for communication

• If the patient has no family, discussions should take place with either the patient’s Attorney with Lasting Powers or an IMCA.

• This information should be recorded on the DNACPR form/patient case notes.

Standard on patient discharge

• DNACPR decision should be reviewed.

• DNACPR form should be given to the patient/relative on discharge from the hospital (assuming they are aware of the decision).

• The DNACPR decision should be recorded within the electronic discharge summary to the GP and should indicate the DNACPR form has accompanied the patient.

What are the issues with DNACPR in UHCW?

Issues with DNACPR in UHCW

• COMMUNICATION

• DOCUMENTATION

• DISCHARGE PROCESS

The current situation (UHCW)DNACPR decision should be discussed with the patient (if they have capacity)

•87% compliant (July 2014)

If the patient lacks capacity the DNACPR order should be discussed with the family

•July 84% compliant (July 2014) 37% compliant (Sept/Oct 2014)

•Issue when DNACPR decision made in ED.

•Plan for discussing DNACPR with relatives not recorded.

•DNACPR decision not reviewed when care transferred to ward consultant. Relatives sometimes never informed/consulted.

•Same on wards - relatives are not available at time DNACPR decision taken. Plan for meeting with them rarely documented.

The current situation (UHCW)

If the patient lacks capacity and has no relatives the DNACPR order should be discussed with the patient’s Attorney with Lasting Powers or IMCA

•Document a patient lacks capacity but the details re: Attorney with Lasting Powers, IMCA’s not always recorded.

DNACPR decisions that are made by an ST3 or above should be countersigned by the consultant within 72hrs

•DNACPR orders made by middle grade staff are rarely countersigned and are often invalid.

•Potential for litigation if fail to resuscitate and DNACPR order invalid.

The current situation in UHCW

DNACPR document should accompany the patient on discharge

•We are not sending DNACPR forms home with the patient (n=142 in 3 months).

•Ward hotspots 30 (n=50) and 31 (n=24) forms from these areas.

•Mechanism in place to try to address issue with the forms.

•42 DNACPR forms actioned.

•100 DNACPR forms in Resuscitation Dept.

•Complaints centred around communication.

DNACPR form should accompany the patient

Ward n= Ward n= Ward n=

Ward 1 7 Ward 21(M) 6 Ward 34 2

Ward 10 4 Ward 22 ECU 1 Ward 35 1

Ward 11 2 Ward 23 2 Ward 40 3

CTCC 1 Ward 30 50 Ward 41 2

Ward 12 1 Ward 31 24 Ward 43 1

AMU 2 4 Ward 33 Renal 1 Ward 50 2

Ward 20 Ward 33 2 Cedar 1

Ward 21(S) 3 Ward 33 Short stay 2 RUCC 1

Unknown 6

Evidence regarding complaints

NHS Trust incidents / complaints, National Reporting and Learning System, Ombudsman, Chief Coroner, Compassion in Dying: End of Life Rights Information Line (Perkins et al 2014).

•Failure to anticipate need for DNACPR

•Clinical staff ignoring patient request for DNACPR

•Discordant views (clinician, patient, relative)

•Lack of information about DNACPR process

•Lack of public understanding DNACPR

•Sub-optimal or lack of patient / family involvement

Evidence regarding complaints

• Poor documentation / record keeping

• Poor handover of decisions

• Failure to withhold CPR when DNACPR in place

• Confusion over processes for form completion

• Confusion about frequency of review

• Harms to patients following CPR

• Fear of adverse consequences following CPR

The future

• All acute admissions should have their resuscitation status reviewed within 12hrs of admission (NCEPOD 2012).

• An alert for resuscitation status is to be added to CRRS.

• Alert to notify Resuscitation Department.

• An electronic DNACPR form will be developed (similar to VTE and dementia).

• National DNACPR policy? Scotland.

• Universal Form of Treatment Options, Cambridgeshire

• DNACPR forms that are recognised across all geographical borders.

• Fundamental Standards of Care are being introduced very soon. Include: person centred care; dignity and respect; need for consent.

• CQC are focusing on DNACPR.

Summary

We need to get DNACPR right to enable patients to have a dignified and natural death at end of their life.