Why is an integrated DNACPR policy needed?
Cardiopulmonary resuscitation ( CPR) is a treatment that could be attempted on any individual in whom cardiac or respiratory function ceases. Such events are inevitable as part of dying and thus, theoretically, CPR could be used on every individual prior to death. It is therefore essential to identify patients for whom cardiopulmonary arrest represents the terminal event in their illness and for whom CPR will fail and/or is inappropriate. It is also essential to identify those patients who would not want CPR to be attempted in the event of an arrest and who competently refuse this treatment option. Some competent patients may wish to make an advance directive about treatment (such as CPR) that they would not wish to receive in some future circumstances. Such directives must be respected as long as the decisions are informed, current, made without coercion from others and clearly apply to the current clinical circumstance.
This policy is intended to prevent inappropriate, futile and/or unwanted attempts at CPR which may cause significant distress to patients and families as a death with an inappropriate CPR attempt may be undignified and traumatic. When a patient dies at home or in a care home an inappropriate CPR attempt is likely also to involve the Scottish Ambulance Service paramedics and even the police, which can add greatly to the distress for the families and be upsetting for all those involved. This policy is intended as a positive step to help a person's wishes to be followed at the end of life irrespective of whether they are being cared for in hospital, hospice, care home or in their own homes.
There is much confusion and uncertainty about CPR and the process of making advance decisions that CPR should not be attempted. Variations in local policies can cause misunderstandings and lead to distressing incidents for patients, families and staff. Increased movement of patients and staff between different care settings in Scotland makes a single integrated and consistent approach to this complex and crucial area a necessity. This policy is in line with current national good practice guidance on decisions relating to CPR, such as the revised Joint Statement produced by the British Medical Association, Royal College of Nursing and Resuscitation Council ( UK) (2007); and the guidance within "Treatment and care towards the end of life: Good practice in decision-making" from the General Medical Council (2010).
In 2006 NHS Lothian implemented the UK's first fully integrated Do Not Attempt Resuscitation ( DNAR) policy with the support of the Scottish Ambulance Service and in 2008 an integrated approach to DNAR was published as an action point for Health Boards within Living and Dying Well, a national action plan for palliative and end of life care in Scotland. In 2009, in response to a specific recommendation from the Public Audit Committee following the Audit Scotland publication "Review of Palliative Care Services in Scotland" the Scottish Government began working on developing a national integrated policy for Do Not Attempt Cardiopulmonary Resuscitation ( DNACPR) decision-making and communication.
Within this policy the term "Do Not Attempt Cardiopulmonary Resuscitation" ( DNACPR) is used rather than "Do Not Attempt Resuscitation" ( DNAR) to help clarify for patients, families and professionals that this policy refers solely to cardiopulmonary resuscitation ( CPR) in the event of a cardio respiratory arrest. It does not refer to other aspects of care e.g. analgesia, antibiotics, suction, treatment of choking, treatment of anaphylaxis etc which are sometimes loosely referred to as "resuscitation".
The advice in this policy should be used in conjunction with the NHSScotland DNACPR form, decision-making framework and patient information leaflet, which can all be found within and appended to this policy. The purpose of the policy is to provide guidance and clarification for all staff working within NHSScotland regarding the process of making and communicating DNACPR decisions. Further information is available at www.scotland.gov.uk/dnacpr
Where patients are admitted to hospital or hospice acutely unwell or become medically unstable in their existing home or healthcare environment their resuscitation status should be considered as soon as is reasonably possible if a cardiopulmonary arrest can be anticipated. Where patients are not acutely medically unstable but it is clear that advanced illness, significant frailty and/or co-morbidity are such that death would not be unexpected it is reasonable to make an advance decision about whether CPR should be attempted.
When no explicit decision has been made about CPR before a cardiopulmonary arrest occurs, and the express wishes of the patient are unknown, it should be presumed that staff would initiate CPR. However, where CPR would clearly fail (for example a patient in the final stages of a terminal illness where death is imminent and expected) it should not be attempted and experienced healthcare workers who make this considered decision should be supported by their colleagues.
Throughout this document the term "relevant others" is used to describe patient's partner, relatives, carers, representatives, advocates, welfare guardians and welfare powers of attorney.