THE PRINCIPLES OF MAKING A DNACPR DECISION
The circumstances of cardiopulmonary arrest must be anticipated
If the circumstances of a cardiopulmonary arrest cannot be anticipated, it is not possible to make a DNACPR decision that can have any validity in guiding the clinical team. In order to make an informed decision about the likely outcome of CPR it is essential to be able to think through the likely circumstance(s) in which it might happen for the patient. It should be recognised that, for some patients with life-limiting illness, significant frailty and/or co-morbidities may be such that death would not be unexpected. For such patients it may be reasonable to make an advance decision about CPR even though a cardiorespiratory arrest is not very imminently expected.
It is an unnecessary and cruel burden to ask patients or relevant others about CPR when it seems unlikely that circumstances would occur where the patient would require CPR. This should never prevent discussions about resuscitation issues with the patient if they wish.
When CPR would fail it should not be offered as a treatment option
In the situation where death is expected as an inevitable result of an underlying disease, and the clinical team is as certain as they can be that CPR would fail (i.e. realistically not have a medically successful outcome in terms of sustainable life), it should not be attempted. In this situation CPR is not a treatment that can be offered and it is an unnecessary and cruel burden to ask patients and relevant others to decide about CPR when it is not a treatment option. Although patients should not be offered CPR where it is clear it will fail, open and honest communication is essential to ensure the patient and relevant others have the opportunity to be made aware of the patient's condition.
Appropriate and sensitive communication and the provision of information are an essential part of good patient care
Good anticipatory care should address the circumstances where CPR might be considered but the timing and nature of conversations about CPR are a matter of judgement for the clinical team. Healthcare professionals should be aware that it is rarely appropriate to discuss DNACPR decisions in isolation from other aspects of end of life care. DNACPR is only one small aspect of anticipatory care planning which can help patients achieve their wishes for their end of life care.
The patient should be given as much information as they wish about their situation including information about CPR in the context of their own illness and sensitive communication around dying and end of life issues. Relevant others can be given such information if the patient agrees. It is not the professional's responsibility to decide how much information the patient should receive, their task is to find out how much the patient wishes to know or can understand. As with all discussions and decisions about end of life care staff must be aware that some patients will want the support of a trusted religious/spiritual advisor during or after conversations about CPR.
Such discussions can result in upset and even anger for patients and their families and are often uncomfortable for healthcare staff, but anticipation of this should not prevent open and honest communication. Where a DNACPR decision is made on medical grounds because CPR will fail, opportunities to sensitively inform patients and relevant others should be actively sought unless it is judged that the burden of such a discussion would outweigh the possible benefit for the individual patient.
These discussions are particularly important for patients who are at home or being discharged home where CPR would be inappropriate because it is not wanted or would fail. There may be clear benefits for patients and their relevant others in being aware of and understanding the positive purpose of the DNACPR form and the reassurance that it can prevent a full emergency response by paramedic ambulance crews and police. It is important for patients at home and their carers to be reassured that a call for urgent assistance will be responded to appropriately by whichever service is contacted.
Discussions about resuscitation are sensitive and complex and should be undertaken by experienced healthcare staff. It is recommended that staff have formal communication skills training in preparation for this clinical responsibility. Any decision-making processes and/or discussions about resuscitation should be documented in the medical, nursing or multidisciplinary notes.
Quality of life judgements should not be part of the decision-making process for healthcare professionals
This policy adopts the view that clinical decisions should be based on immediate health needs, and not on a professional's opinion on quality of life. This is primarily because opinions on quality of life made by health professionals are very subjective and often at variance with the views of the patient and relevant others. Where CPR may be medically successful in achieving sustainable life, it is essential to know the patient's fully informed views on the burdens and benefits for them of this treatment and its likely outcome.
Where no advance decision about CPR has been made there should be an initial presumption in favour of providing CPR
When no explicit decision has been made about CPR before a cardiopulmonary arrest occurs, and no expressed wishes of the patient are known, it should be presumed that staff would attempt to resuscitate the patient. However, although this should be the initial presumption there will be some patients for whom attempting CPR would fail, for example a patient in the final stages of a terminal illness where death is imminent and unavoidable. Where CPR will fail it should not be attempted and experienced healthcare professionals who make this considered decision should be supported by their colleagues.
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