DNACPR Post-LCP conference Arundel Hilton 14 May 2014

1. DNACPRPost-LCP conferenceArundel Hilton14 May 2014 Brendan Amesbury

2. Plan for session • What is CPR? • Examples of poor practice • How successful is CPR? Evidence • Why are DNACPR orders needed? • Go over the SHA process and principles • Look at which patients get a DNACPR order • Range of scenarios for which DNACPR may be completed • Which patients are eligible for DNACPR orders? • Unpack principles including the single pan-Kent, Surrey & Sussex DNACPR form • Who can sign the form? • DVD: Model conversation about deterioration and resus • Does a paramedic always need to see a DNACPR form? • Accessing DNACPR forms • Where do patients keep the form at home? • Good practice examples • Consider ways of introducing DNACPR discussions • Questions

3. What is CPR? • In a situation of cardiac and respiratory arrest … • External cardiac compression • Defibrillation • Artificial respiration • Not about faints; "collapse"; unconsciousness etc • Not IV fluids, antibiotics etc • Not like on television (Casualty) or in newspapers (Daily Mail!) • There is a very low success rate even on ITU

4. Poor practice example 1 – giving option • Patient with advanced malignancy, progression on CT, albumin 14 • Admitted to hospital with new confusion and aphasia • Investigations: concluded EOL soon. Family informed • House officer told to “sort out the DNACPR” • Resus option put to family by FY1 as though there was a choice • “We want it“ • Muddle, uncertainty … • Registrar involved, DNACPR completed • Patient died 2 days later

5. Poor practice example 2 – signing form and communication • Hospital patient with advanced malignancy • Medical team know patient to be dying, transfer to hospice planned • Daughter consulted about resus decision • “I was asked to sign the form” • “Signing mother’s death warrant” • Somehow family still not aware of imminent death … • Transfer to hospice, died after 4 hours • Family shocked • Quasi-complaint led to meeting at SRH incl non-exec director with remit for EOLC

6. Evidence for benefit or, otherwise, of CPR in people with advanced disease • 0% survival for cancer patients with an anticipated arrest due to a pre-existing condition unresponsive to treatment. Ewer • 2% survival after arrest for cancer patients spending more than 50% of the day in bed. Vitelli • 2% survival for cancer patients with an anticipated arrest occurring in an ICU. Wallace. MD Anderson, Houston Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer. 2001;92(7):1905-12. Vitelli CE, Cooper K, Rogatko A, Brennan MF. Cardiopulmonary resuscitation and the patient with cancer. J Clin Oncol. 1991;9(1):111-5. Wallace SK, Ewer MS, Price KJ, Feeley TW. Outcome and cost implications of cardiopulmonary resuscitation in the medical intensive care unit of a comprehensive cancer centre. Support Care Cancer. 2002 Jul;10(5):425-9.

7. Why are DNACPR orders needed? • The default option is "for resus" • In acute care high levels of resus skills and tech – but not all cardiac arrests warrant CPR • In community setting a "collapsed " person – in end of life care context someone who has died – gets resuscitated if a 999 ambulance is called – unless a DNACPR order is in place • Lots of examples of distressing (to family & paramedic) CPR in community when peaceful death was planned

8. South East Coast process & principles • In 2010 South East Coast SHA End of Life Clinical Advisory Group established a DNACPR subgroup to write "over-arching principles" for DNACPR • Principles to be followed by all organisations, NHS and other, including ambulance trust • Principles, when unpacked, are: • Follow BMA/RC/RCN guidelines • Follow Nursing & Midwifery Council guidelines about senior nurses issuing DNACPR orders • Use GMC end of life guidance • SECAMB to be aware "no expiry date“, no need to change address on form if patient moves to eg care home • Use (modified) Resus Council model form with red "active" form & grey copy for circulation. Used by WSHT, hospices, community

9. Reason for issue of DNACPR form Cancer 36% Dementia 24% Advanced age or frailty 7%

10. Potential resuscitation scenarios • Emergencies – sudden cardiac arrhythmias, RTA, drowning • Progressive illness where a cardiac arrest might occur • End-stage illness where end of life care is planned and a cardiac arrest might occur – but also death can be anticipated • ADRT advance decision to refuse treatment where patient has said "Don't want CPR"

11. Emergencies • Sudden cardiac arrhythmias, RTA, drowning etc • No advance decision about resus possible

12. Progressive illness • Where a cardiac arrest might occur, but with a good chance of successful resus – eg early heart failure • May be appropriate to make an advance decision about resus – ie DNACPR order • Patient MUST be consulted and involved in the decision

13. End stage illness - EOLC • Where EOL care is planned, a cardiac arrest might occur, but clinical assessment is of a very low possibility of successful CPR ie end stage heart failure, advanced cancer • We have ethical duty to act in the patient's best interest, and only to offer Rx that are going to be effective, therefore resus is not a treatment the patient would be given • Since resus is not going to be given, clinician can't discuss resus as an option with the patient, • Equally the clinician can't ask the patient's wishes • But clinician may need to explain the situation to the patient and carers and inform them that a DNACPR order is made • Don't always have to inform patient/carers a DNACPR order has been made – eg in the expected EOLC in-patient setting

14. ADRT • Patient has made advance decision to refuse CPR • Legally binding as part of MCA • Must be a properly completed form witnessed, stating aware life at risk • Not very common at present

15. Which patients are near end of life and/or eligible for DNACPR orders? Patients are "approaching EOL" when they are likely to die within the next 12 months. This includes patients whose death is imminent (expected within a few hours or days) and those with: (a) advanced, progressive, incurable conditions (b) general frailty and co-existing conditions that mean they are expected to die within 12 months (c) existing conditions if they are at risk of dying from a sudden acute crisis in their condition For such patients it may be appropriate to consider a DNACPR order. Adapted from “paragraph 2 of GMC’s Treatment and care towards the end of life"

16. Principle 1 • BMA/RC/RCN joint statement 2007 • Guidance for best practice • Widely followed • Using it as basis for DNACPR decisions is straightforward • Expecting a revision soon

17. 6.1 Communicating DNACPR decisions to patients in EOLC situations • When a clinical decision is made that CPR should not be attempted, because it will not be successful, and the patient has not expressed a wish to discuss CPR, it is not necessary or appropriate to initiate discussion with the patient to explore their wishes regarding CPR • In most cases a patient should be informed, but for some patients, for example, those who know they are approaching the end of their life, information about interventions that would not be clinically successful will be unnecessarily burdensome and of little or no value • Clinicians should document the reason why a patient has not been informed of a DNACPR order if the decision is made not to inform the patient

18. 6.2 Requests for CPR in situations where it will not be successful • Neither patients, nor those close to them, can demand treatment that is clinically inappropriate. If the healthcare team believes that CPR will not re-start the heart and breathing, this should be explained to the patient in a sensitive way. These discussions informing the patient of the healthcare team’s decision may be difficult and where possible should be carried out by experienced senior clinicians. If the patient (or family) does not accept the decision and requests a second opinion, this should be arranged whenever possible.

19. Principle 2 • NMC guidance from 2008 • Less well-known • Re-iterates BMA/RC/RCN guidance that "senior nurses with appropriate training" may complete DNACPR orders • Likely to be used mainly by hospice CNSs and community nurses

20. Principle 3 • GMC end of life guidance • Published May 2010 • Describes best practice including: • DNACPR • Diagnosis of EOL • Use of Prognostic Indicator Guidance (PIGs) from GSF • Advance care planning • Team work

21. From GMC's Treatment and care towards EOL Paragraph 134 If … you judge that CPR should not be attempted … you must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made. While some patients may want to be told, others may find discussion about interventions that would not be clinically appropriate burdensome and of little or no value.

22. Principle 4 • SECAMB guidance from 2009 • Ambulance crews must see original form • No review date unless stated • Also no need to change address if move to care home. Name, dob, NHS number etc

23. Principle 5 • Resus Council model form • Modified from original by WSHT Resus Committee, pall med team, PCT • Red form is the valid form; • Remains valid unless a review date specified • Will be patient-held • "Travels" with patient – ie applies wherever the patient is located • In patient's home should be kept in Message in A Bottle container

24. Principle 5 continued • Grey decision record • Carbon copy • Kept in patient notes • Grey form to be circulated to other providers • Can be faxed to ambulance trust, OOH provider, GP etc • Form completion guidance notes also printed in the pads.

25. Who signs the DNACPR decision? Form has two signing sections • Section 6 for professionals in lieu of "most senior professional" – ie OOH doctors, hospital registrars etc. • Section 7 for "most senior professional" ie consultant or GP or trained senior nurse • If those people are making the order then section 6 can be struck out

26. DVD • Model conversation about deterioration and resus • 8 minutes • Cathy Gleeson from St Catherine’s Hospice, Crawley

27. Does a paramedic always need to see a DNACPR order? • No. JRCALC Resuscitation Supplement stated 2010: • “In the following condition resuscitation can be discontinued – a patient in the final stages of a terminal illness where death is imminent and unavoidable and CPR would not be successful, but for whom no formal DNAR decision has been made”

28. How has this been implemented at SECAMB? In 2013 extended the DNACPR policy to include the following: • Documentation in patient’s notes that confirms they have a terminal illness, eg hospital, hospice or district nursing notes • Documentation in patient notes that they have reached the terminal phase of an illness (last weeks or days of life) • Evidence that the patient is on LCP or other care plan used in the last days of life • A Preferred Priorities of Care Document, Advance Care Plan or statement of wishes indicating patient choice not for resus • A signed advance decision to refuse treatment (ADRT) stating that the patient does not wish to undergo resus Evidence that the patient is suffering from a serious illness such as cancer is insufficient unless there is clear evidence that the patient has entered the terminal phase of their condition

29. Accessing DNACPR forms • Carbonated pads of forms printed • Distributed to hospital wards, hospices and GP practices • Sussex Community Trust – ie district nurses – have forms • Forms are located online at WSHT referral guidelines website (palliative and end of life section) and hospice websites

30. Where do patients keep the form at home? Green Message In A Bottle containers • Bottles funded by Lions Clubs • DNACPR order (plus other advance care planning tools) goes in the green bottle • One green sticker goes on back of front door; second sticker on front of fridge door • Bottle goes in fridge on a door compartment/shelf • Ambulance crews aware to look on back of front door for a green sticker – then locate fridge • Sourcing of supplies of containers – is on hospice and WSHT guidelines websites • Currently not easy to access containers in WSHT

31. Two recent examples of DNCAPR ordersCase 1 • RC, 69 year old with MND • Hospice in-patient with DNACPR order in place • Due to be discharged home • Patient not keen to discuss future plans, happy for wife to be involved • Wife aware of DNACPR order and keen to have in place at home • Order given to wife, along with MIAB container, to take home • Copy to GP, ambulance OOH etc

32. Two recent examples of DNCAPR ordersCase 2 • AC, 87 year old with Ca pancreas • Patient living at home alone • First assessment at home by hospice CNS when patient's son also present • Future care discussed • Patient asked to have DNACPR order put in place • Completed by hospice Dr, original given to patient, along with MIAB • Copy sent to GP, ambulance service, OOH etc

33. Talking to a patient about CPR status 1 Explanation about probability of dying and the changing focus on managing symptoms and looking at some things that would not be of benefit • “We are concerned you may be dying now and that we need to focus on maintaining your comfort” • “There are some procedures that will not help and will probably cause you more suffering such as resuscitation" • "I'd like to talk about what would happen if you collapsed at home – perhaps when you are very ill and had in fact died – has anyone talked to you about resuscitation?"

34. Talking about a patient's CPR status 2 As part of advance care planning. Give patient a copy of "Planning for your future care" and follow-up once patient has read • “If your condition deteriorated what would you want to happen to you?" • "Has anyone talked to you about resuscitation?" • "What is your understanding of what CPR means?"

35. Talking to a patient about CPR status 3 Assessing current understanding of condition, clarification of the current situation by suggesting a poor outlook so providing a warning shot • “Tell me what you understand about how your illness is progressing and how you see the future going" • “We are concerned about your condition, you don’t appear to be getting any better. What do you think?” • “We would like to talk about your future care and management, would that be OK?” • Last slide

36. Meant to be a workshop … but some many of you interested … Question? What problems do you encounter in clinical practice? Comments? Observations?