Do Not Attempt Resuscitation (DNAR) Policy - Dudley Primary Care ...

Do Not Attempt Resuscitation (DNAR) Policy
Document Description
Document Type Policy
Service Application Dudley Primary Care Trust and Dudley Community
Services
Version 1.0
Ratification date 29 April 2010
Review date May 2011
Lead Author(s)
Trish Squire End of life Care Manager
Megan Page Community Macmillan Nurse
Linda Plant Case Manager
Presented for discussion, approval and ratification to
Core Policies and Procedures Group 29/04/2010
Change History
Version Date Comments
0.1 05/05/10 DNAR section removed from main CPR Policy and
developed into a separate policy, following
discussion at core policy group.
0.2 14/05/10 Formatting changes.
0.3 19/05/10 CQC Regulations added.
1.0 24/06/10 Final Ratified Version.
Link with Care Quality
Commission Essential
Standards of Quality and
Safety
Link with Trust Purpose
and Values statements
Regulation 9, Outcome 4 – Care and welfare of
people who use services.
Regulation 17, Outcome 1 – Respecting and
involving people who use services.
Regulation 18, Outcome 2 – Consent to care and
treatment.
Regulation 20, Outcome 21 – Records.
Regulation 24, Outcome 6 – Co-operating with
other providers.
We will be open and honest in our approach.
We will value equality and diversity and ensure
that everyone is treated with respect.
We will strike to secure seamless services that
best meet the needs and preferences of the
community.
We will embrace partnership working
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Summary Sheet
Every patient has the right to die in peace and with dignity and there will
inevitably be cases where resuscitation following cardio-respiratory arrest
cannot be justified on medical or quality of life grounds, as being in the
patient's interests.
It may also be against the clearly stated wishes of the patient to prolong what
the patient sees as a poor quality of life by attempting Cardio-Pulmonary
Resuscitation (CPR).
Such cases should be clearly identified and all staff involved in the patient’s
care should be made aware of the action to take in the event of cardiorespiratory
arrest.
The aim of this Policy is to:-
• Ensure that clinicians understand the key ethical and legal issues that
are used as a framework to inform decisions about CPR and when not
to resuscitate a patient.
• That clinicians clearly document these decisions using the required
paperwork.
• That these decisions are clearly and correctly communicated to all
other providers and outside organisations that may be involved in the
patient’s care.
These guidelines do not address the complex legal, ethical and clinical issues
that surround some cases and in this instance clinicians are advised to seek
further guidance and support from senior management. This policy relates
specifically to Do Not Attempt Cardio-Pulmonary Resuscitation and does not
replace the existing Dudley CPR Policy (2009). Neither does it refer to other
life sustaining treatments.
This is a Trust wide policy for the attention of all clinicians and it is
recommended it is read in conjunction with the following local and national
documents:
Decisions relating to cardio-pulmonary resuscitation. The revised joint
statement from the British Medical Association, Resuscitation Council (UK)
and the Royal College of Nursing (2007)
Resuscitation – Do not resuscitate orders position statement. Nursing and
Midwifery Council (2000)
Withholding and withdrawing Life Sustaining Treatment- Guidance for doctors.
Good Medical Practice (2006)
End of Life Care Strategy (DH 2008)
End of Life Care Pathway (West Midlands Clinical Pathway Group 2008)
Dudley PCT Baseline Review of Services for End of Life Care (DH Operating
Framework 2007/08)
Advance Care Planning: A Guide for Health and Social Care Staff (NHS End
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of Life Care Programme 2007)
End of life Care Programme (NHS) (2004-2007)
Mental Capacity Act (2005)
Dudley PCT Mental Capacity Policy (2008)
Preferred Place of Care Document
(www.endoflifecareforadults.nhs.uk/eolc/ppc.)
Liverpool Care Pathway (www.mcpcil.org.uk)
Gold Standards Framework (www.goldstandardsframework.nhs.uk)
The DNAR Policy is subject to formal review after 1 year and every 2 years
thereafter. The review will be undertaken by the End of Life Care Manager in
consultation with the Specialist Palliative Care and End of Life Care Steering
Group. A review of this guidance may occur at any time if it is deemed
necessary by this group.
This Policy was developed in consultation with the following:
GP, Medical Director Mary Stevens Hospice
Resuscitation Officer, Dudley Group of Hospitals
End of Life Clinical Lead,, West Midlands Ambulance Service
GP, PEC Chair
Senior Solicitor, Mills & Reeve
Macmillan Specialist Nurse
District Nurse Out of Hours Manager
Primecare Manager
Associate Director of Governance
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Contents
Pg No
Introduction 5
Scope 5
Patients who wish to make a DNAR decision 5
Guidelines for DNAR decisions 6
Documentation of the decision 6
Patient transfers 7
Review of the DNAR decision 8
Communication of the DNAR document 8
Clinical and Professional conflict 9
Summary 10
References 10
Appendix 1 DNACPR form 11-14
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Non-performance of Cardio-Pulmonary Resuscitation
Introduction
The decision not to provide cardio-pulmonary resuscitation (CPR) to a patient
should be made before the patient goes into cardiac arrest, ensuring the
consideration of all relevant legal principles and be correctly communicated to
all appropriate staff. A decision not to resuscitate can only be made by an
appropriate Consultant/GP or by the patient if they are an adult and with
mental capacity to make that decision. If a patient does not want to be
resuscitated or medical doctor and/or nursing staff feel that resuscitation
would be inappropriate the Consultant/GP responsible for that patient’s
treatment should be informed immediately.
Scope
This policy applies to all clinicians working within Dudley community and
primary care services and other organisations who deliver care to patients
registered with a Dudley GP such as Dudley Group of Hospitals, Medical Out
of Hours providers and Care Homes.
1. Patients wishing to make an advance decision relating to Do Not
Attempt Resuscitation (DNAR)
1.1 Healthcare professionals have an important role in helping patients
participate in advance care planning and making appropriate plans for
their future care in a sensitive but realistic manner, making it clear
whether or not attempted CPR could be successful.
1.2 A competent patient can make an Advance Decision to Refuse
Treatment (ADRT) including life sustaining treatment such as CPR as
outlined in the Mental Capacity Act (MCA) (2005). These legally binding
decisions have to be made within the legal framework outlined within the
MCA (2005) and recorded in the written format recommended within the
Act. Health Professionals are bound to comply when the refusal
specifically addresses the situation that has arisen. Resuscitation should
not be attempted if CPR is contrary to the recorded, sustained wishes of
an adult who was mentally competent and aware of the implications at
the time of making that advance decision.
1.3 In 2007 the British Medical Association, the Royal College of Nursing
and the Resuscitation Council (UK) published a joint statement on
decisions relating to CPR which considers these issues in more detail.
Professionals should refer to that statement if they are approached by a
patient to make an ADRT. Further information is also contained in the
Mental Capacity Act in Practice: Guidance for End of Life Care (2008)
published by the National Council for Palliative Care and the MCA
(2005).
NB Adults who lack capacity
Patients over 16 years of age are presumed to have capacity to make
decisions for themselves unless there is evidence to the contrary. Refer to the
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British Medical Association, the Royal College of Nursing and the
Resuscitation Council (UK) 2007 for further guidance on this complex area
and the MCA (2005) or Dudley MCA Policy (2008) for assessment of capacity
guidelines and assessment tools.
2. Guidelines for Do Not Attempt Resuscitation decisions
2.1 The overall responsibility for a decision that a patient should have a
DNAR order rests with the senior member of the Medical Team available
(Consultant or GP) in charge of the patient’s care. This should be made
after appropriate consultation and consideration of all aspects of the
patient’s condition. It is important that Consultants, GP’s or Senior
Nurses, etc. lead and counsel their junior staff during such decisionmaking.
2.2 It is appropriate to consider a DNAR decision in the following
circumstances:-
• The likely clinical outcome, including the likelihood of successfully
restarting the patient’s heart and breathing, and the overall benefit
achieved from a successful resuscitation.
• The patient’s known or ascertainable wishes.
• The patient’s human rights, including the right to life and the right to
be free from degrading treatment.
2.3 A DNAR order applies solely to the treatment of cardio-pulmonary
resuscitation in a cardiac or respiratory arrest. Other forms of treatment
are not precluded and must not be influenced by a DNAR decision.
2.4 Proper understanding of a DNAR order is impossible without knowing the
rationale behind it. The reasons for any decision not to resuscitate,
together with the discussion with the patient and/or relatives and/or
friends, must be fully documented in the patient’s medical record and the
senior member of the Medical Team or GP must ensure that the decision
is effectively communicated to other members of staff. The decision not
to resuscitate must then be clearly noted in the nursing care plan/ Single
Assessment Process (SAP). A reasonable explanation as to why the
decision has been made must be stated. It is not acceptable simply to
record ‘Not For Resuscitation’.
3. Documentation of the Decision
3.1 Whilst national guidance suggests that a GP, Consultant OR Senior
nurse may sign the DNAR form, Dudley’s Policy doesn’t support this. If
the patient’s GP or Consultant is the first person signing then a second
signature is not required. However if a senior nurse is the first signatory
then the patient’s GP or Consultant must countersign the form as the
second person signing.
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3.2 If there is disagreement between professionals or the patient or family
members regarding the DNAR decision it would be best practice to have
the document countersigned by another senior clinician who knows the
patient.
3.3 It is important that once the DNAR decision has been made that a
recognised document is used. It is quite acceptable to use the National
Resuscitation Council’s document, Dudley PCT’s own DNAR document
or the new combined West Midlands Ambulance Service (WMAS) and
Dudley DNAR form (see appendix 1).
3.4 It is also important that once the DNAR decision has been made, that it
is recorded in both the medical case notes and the nursing care plan. It
is the responsibility of the nurse in attendance to transcribe the decision
into the nursing notes.
The only acceptable entry in the medical and nursing case notes will be: -
‘Not For Cardio-Pulmonary Resuscitation’
Or
‘Do Not Attempt Cardio-Pulmonary Resuscitation’
3.5 It is unacceptable practice to use abbreviations, codes or symbols to
denote the patient’s resuscitation status. Such practice could lead to
confusion or misunderstanding.
3.6 The date of the decision must be recorded along with the next scheduled
review date (if appropriate, see point 5.2).
3.7 The patient’s known wishes must always be communicated when
referred or discharged to another service.
3.8 Health Care Teams will ensure that patients are treated with respect and
dignity, and that every effort is made to avoid a “conspiracy” of silence,
from the patient’s perspective, about his/her resuscitation status.
NB If the new WMAS form is used then please follow the guidance notes for
completion.
4. Patient Transfers
Documentation required when a patient who is designated Not for Cardio-
Pulmonary Resuscitation and is being transferred across different care
settings or a different provider. There are two sets of occasions when
patients are being transferred and these will need to be dealt with differently.
4.1 When the patient remains under the care of the Consultant / GP making
the decision (transfer across sites).
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In this case the Consultant / GP must appropriately communicate to the
staff concerned that the patient is not for resuscitation using the form in
appendix 1.
4.2. The patient has been discharged to the care of another Consultant or
his/her GP.
In this case it is necessary for the Consultant or GP to communicate all
relevant clinical information, including that relating to non-resuscitation,
to the doctor assuming the care of the patient. However, the Consultant
or GP cannot issue a directive concerning the management of a patient
who is no longer under his/her care. Only the responsible doctor can
take this decision. The ambulance staff should receive guidance from
the appropriate doctor when transporting a patient who is not to be
resuscitated. Any communication with ambulance staff should be either
written in patients single assessment process (SAP) folders or via
ambulance control if alert is flagged on the patients address. This will
ensure there is a permanent record of the instruction as all telephone
conversations with ambulance control are recorded.
5. Review of the Decision regarding Patient’s Resuscitation Status
5.1 The Law does not prescribe the frequency with which reviews must be
undertaken. Any order not to resuscitate however, should be reviewed
regularly since the frequency or otherwise of the review will be produced
in evidence in the course of litigation arising from this type of case.
Therefore a review should be undertaken at least six monthly by the
multi-disciplinary team, as the patient resuscitation status may change as
a result of either a change in health or a change in legal status of the
patient. Such changes must be recorded and communicated to all
members of the health care team
5.2 There will be situations where the decision will stand indefinitely and
review may be unnecessary, i.e. terminal care for malignancy etc.
Documentation in the notes for such scenarios must be clear,
unambiguous and also documented in all patient notes.
5.3 The clinician-in-charge has a duty to keep the medical staff informed of
any changes in the patient’s condition and must do so particularly if
he/she considers it likely that the patient’s resuscitation status could be
affected.
6. Communicating Do Not Attempt Resuscitation Decisions Made
6.1 Assuming that the decision has been made following the above
guidelines and documented accordingly, it is the senior medical or
nursing professional’s responsibility to ensure that it is readily accessible
to all health professionals who may need to know it, including hospital
staff, GPs, deputising services, Out of Hours services and ambulance
staff.
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Please note that there are now two new forms (appendix 1) to document
and transfer the information across to Out Of Hours providers and West
Midlands Ambulance Service (WMAS).
6.2 Part one of the form is the DNAR document and may replace the
organisations existing form. However if a DNAR form has already been
made and is valid then there is no need to replace it. This form must
stay with the patient held notes in the patient’s own home and must not
on any account be photocopied.
6.3 Part two of the form is the document required to transfer the information
to WMAS. This information may be the DNAR status of the patient but
may also be other information regarding end of life care, management
and or patient preferences regarding place of care. This part of the form
is to be faxed to WMAS (using the safe-haven fax number on the form).
6.4 By following the guidelines on the form the patient’s DNAR status, and or
other end of life care preferences or management, will be registered with
WMAS. In the event of an emergency call to the ambulance service the
crew will then be aware that there is a DNAR document in the house and
will also have additional information if the special patient notes have
been completed as well.
6.5 WMAS will confirm receipt of the fax within 30 minutes of receiving it and
will inform the named clinician on the form if they are called to the
patient.
6.6 The clinician completing the form is responsible for informing WMAS of
any changes to the patient clinical status, including DNAR status, if the
patient dies or if the patient has changed address.
6.7 If WMAS are called out to the patient they will inform the lead clinician of
the outcome on the next working day.
6.8 The form can also be faxed to Medical and District Nursing OOH using
the existing arrangements for special patient notes for palliative and end
of life care patients.
7. Clinical and Professional Conflict Resolution
7.1 Where there is clinical and professional conflict over the decision taken
about the patient’s resuscitation status, urgent decisions must take place
between the Senior Medical Practitioner and the local manager. If the
matter cannot be resolved at local level, then the Medical Director and
senior management lead must be involved as a matter of urgency. As
this is a complex area of law the Consultant or GP may also wish to seek
specific legal advice via the Chief Executive’s Office.
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8. Summary
• There are no rules about who should or should not be resuscitated. The
Healthcare team must consider every case individually in collaboration
with the patient and their carer(s).
• The use of a ‘blanket policy’ for who should or should not be resuscitated
is illegal and is contrary to the professional duty of the Trust’s staff, who
are expected to act in the best interests of the individual patient at all
times.
• Healthcare professionals need to be aware of the law in relation to
decision making for different groups including adults with mental capacity
to make decisions about their treatment.
• It is important to note that an adult’s relatives/carers have no legal right to
give or withhold consent for resuscitation, unless they have been given
Lasting Power of Attorney for Health Decisions by the patient/client.
However, their views must be sought whenever possible and taken into
account before a decision is made.
• Where there is concern or confusion about resuscitation, the offer of a
second opinion by an appropriate specialist should be made available to
the patient or relatives/carers. Until such a decision has been reached the
situation should be treated as that of an “emergency situation”.
References
British Medical Association, Resuscitation Council (UK) and the Royal College
of Nursing (2007) Decisions relating to cardio-pulmonary resuscitation. (The
revised joint statement)
Mental Capacity Act (2005) The Lasting Powers of Attorney, Enduring Powers
of Attorney and Public Guardian Regulations.
Nursing and Midwifery Council (2000) Resuscitation – Do not resuscitate
orders position statement NMC.
Resuscitation Guidelines (2005) Resuscitation Council (UK) London.
Withholding and withdrawing Life Sustaining Treatment- Guidance for doctors.
(2006) Good Medical Practice.
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Appendix 1
Can be used in all care settings
Do Not Attempt Cardio Pulmonary Resuscitation
Patient Details
Patient Name NHS No.
Date of Birth GP
Address Practice
Postcode Tel No.
Tel No. Fax No.
Next of Kin Support Provider ( note 1 overleaf)
Name Name
Relationship Role
Tel No. Tel No.
Mobile Mobile
Action to be undertaken in the event of Cardiac Arrest
Cardio Pulmonary Resuscitation (CPR) is not to be undertaken on this patient because:
(Please tick all relevant boxes)
Attempting CPR is unlikely to restart the patient’s heart and breathing.
The expected benefit of the treatment is outweighed by the burdens.
Attempting resuscitation is against the competent patients expressed wishes.
Discussion has taken place with: The patient
The patients relative/significant other
(Name _________________________________ )
This DNACPR is only to be adopted in the case of cardiac/respiratory arrest. All other
appropriate medical support should still be provided
Clinicians’ Details
First Person Signing Second Person Signing (note 2 overleaf)
Designation: Designation:
GMC/NMC Pin: GMC/NMC Pin:
Address Address
Tel Number: Tel Number:
Review Date
(state continuous if not for review):
Signature: Date Signature: Date
Once the DNACPR is completed the WMAS Single Point of Access should be
informed of the details (see note 3 overleaf)
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Review
Review 1 Review 2
Clinician Name: Clinician Name:
Designation: Designation:
Date reviewed: Date reviewed:
Date for Review: Date for Review:
Signature: Signature:
This space can be used for any general statement of wishes including
preferred place of care. If a formal Advance Decision Refusing
Treatment is required the Patient is advised to use a separate document.
Notes on completion of the form:
1. Giving this information enables WMAS to call this relative, friend or professional for
support after they have left the patient’s address.
2. The patients GP, Consultant or senior nurse can sign as first signatory. However the GP
or Consultant MUST sign as the second signatory (as soon as possible) if the senior
nurse is the first signatory. In complex situations or when there is disagreement about a
DNAR decision it is recommended as best practice to have 2 signatories from clinicians
who know the patient.
3. Notifying WMAS of the existence of this form will allow Emergency Clinicians the
knowledge of this DNACPR – Please fax details (see enclosed form) to the SPA Hub
4. Notifying WMAS will facilitate the uploading of details onto the WMAS computer (CAD)
system. Although the form is still valid without this communication, this is important
information for WMAS. Make sure the form itself stays with the patient
5. The clinician completing the DNACPR should ensure that all relevant fields are completed
on page one.
6. If the DNACPR is withdrawn the Single Point of Contact SPA HUB should be informed
immediately so that the DNACPR can be removed from the patients address on the CAD
system.
WMAS - October 2009
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Fax No. 01926832898 ( 24 hours)
Tel No. 01926885082 (24 hours)
Date: __________________
I wish to inform you that a DNACPR/Patient Notes (delete as appropriate) has been made
for:
Patient Details NOK Details (as appropriate)
Patient Name Name
Date of Birth
Address Address
Postcode Postcode
Tel No. Tel No.
NHS No.
PT Diagnosis
Authorised Practitioner Details
Name
Job Title
Contact No.
Patient GP
Practice
Address
Postcode
Tel No.
Special Notes - Please details any special patient notes in this section – i.e. telephone numbers, referral
routes, out of hour’s information, clinical advice ….
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Special Notes
Please details any special
patient notes in this section
– i.e. telephone numbers,
referral routes, out of
hour’s information, clinical
advice ….
If you require any further information please do not hesitate to contact WMAS.
Upon receipt of this form a WMAS representative will contact you to validate this
request within 30 minutes (24 hours a day)
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