DNACPR Flashcards
Who can sign a DNACPR form?
The responsibility of DNACPR decisions lies with the senior doctor responsible for the patient during their admission - typically the consultant
Can Foundation Doctors ever sign DNACPR forms?
If you have a full licence to practice then you are able to sign DNACPR forms i.e. if you do not have a full licence, you must not complete a DNACPR form.
However, if a situation occurs where a foundation doctor is required to sign the form, they must fully discuss the decision with the senior clinician who must then countersign the form as soon as possible.
When should you consider making a DNACPR decision?
If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful in restarting breathing and circulation, discussing, making and recording a decision in advance not to attempt CPR can help to ensure the patient dies in a dignified and peaceful manner.
In cases in which CPR might be successful, it might not be seen as clinically appropriate because of the potential for poor clinical outcomes. When considering whether to attempt CPR, consider the benefits, burdens, and risks of treatment that the patient may need if CPR results in the return of a spontaneous circulation. In cases where you assess that such treatment is unlikely to be clinically appropriate, you may conclude that CPR should not be attempted. Some patients with capacity to make their own decisions may wish to refuse CPR; or in the case of patients who lack capacity it may be judged that attempting CPR would not be of overall benefit to them.
if a patient is admitted to hospital acutely unwell or becomes clinically unstable in their home, and they are at foreseeable risk of cardiac/respiratory arrest, a judgement about the likely success of CPR and its benefits, burdens and risks should be made as early as possible. Also check whether any form of advance care planning is already in place, and if the patient lacks capacity, whether they have a legally binding advance refusal.
Outline the key features of a discussion with a patient who has capacity about DNACPR decisions.
Decisions made in advance about whether CPR should be attempted must be based on the circumstances of the individual patient and take into account their wishes and preferences and should involve discussions with members of the MDT as well as those close to the patient (with the patient’s agreement). You must approach discussions sensitively and bear in mind that some patients or those close to them, may have concerns that decisions not to attempt CPR might be influenced by poorly informed or unfounded assumptions about the impact of disability or advanced age on the patient’s quality of life.
Outline the key features of a discussion with a patient who lack capacity about DNACPR decisions.
Consult those close to the patient and must approach discussions sensitively and bear in mind that some people may have concerns that some decisions not to attempt CPR might be influenced by poorly informed or unfounded assumptions about the impact of disability or advanced age on the patient’s quality of life. In addition, the views of members of the healthcare team involved in their care may be valuable in assessing the likelihood that CPR would be successful in restoring the patient’s breathing and circulation or whether successful CPR would likely be of overall benefit to them. You must make reasonable efforts to discuss a patient’s CPR status with these healthcare professionals.
What is the basis of a conversation with a patient about a decision not for DNACPR?
If a patient is at foreseeable risk of cardiac/respiratory arrest and you judge that CPR should not be attempted, because it will not be successful, you must sensitively discuss this with the patient unless this would cause them serious harm. The purpose of the dialogue is to reach a shared understanding with the patient about their situation, your judgement and your reasons for reaching it. You must listen to the patient and you should encourage them to ask questions. As part of these discussions, you should explore with the patient the type of information they want or need, their wishes or fears and explain that they have a right to seek a second opinion. While some patients may want to have these discussions, others may not. You should not force a discussion or information onto the patient if they do not want it. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.
What do you do if a patient does not want to discuss a DNACPR decision?
If the patient does not wish to know about or discuss a DNACPR decision, you should seek their agreement to share with those close to them, with carers and with others, the necessary information they may need to know
in order to support the patient’s treatment and care. You should emphasise to the patient that they may discuss the topic at any time if they decide that they want to.
Who do you discuss a DNACPR decision with when a patient lacks capacity?
If a patient lacks capacity, you must consult with any legal proxy and others close to the patient about the DNACPR decision and the reasons for it unless it is is not practical or appropriate to do so. These discussions should take place at the earliest opportunity and include a sensitive and careful explanation that the intent is to spare the patient treatment that will be of no benefit, not to withhold any other care or treatment the patient will need.
What is the basis of the discussion with a patient who is suitable for resuscitation?
If CPR may be successful, the benefits must be weighed against the potential burdens and risks. This is not solely a clinical decision. You must offer the patient opportunities to discuss (with support if they need it) whether CPR should be attempted in the event of a future cardiac or respiratory arrest. You must approach this sensitively and should not force a discussion or information onto the patient if they do not want it. However, if they are prepared to talk about it, you must provide them with accurate information about the burdens and risks of CPR, including the likely clinical and other outcomes if CPR does restore breathing and circulation. This should include a sensitive explanation of the extent to which other intensive treatments and procedures may not be seen as clinically appropriate after the return of spontaneous circulation. For example, in some cases, prolonged support for multi-organ failure in an intensive care unit may not be clinically appropriate or of overall benefit even though the patient’s heart has been restarted.
What do you do if a patient requests CPR but you do not think it is appropriate?
If a patient wishes to receive CPR and it is your considered judgement that CPR would not be clinically appropriate for the patient, you must sensitively explore their reasons for requesting it, their understanding of what it would involve, and their expectations about the likely outcome. As part of this, you should make sure that they have accurate information about the nature of CPR and, for example, the length of survival and level of recovery that they might realistically expect if they were successfully resuscitated. You should also try to reach agreement; for example, limited CPR interventions could be agreed in some cases. When the benefits, burdens and risks are finely balanced, the patient’s request will usually be the deciding factor. If, after discussion, you still consider that CPR would not be clinically appropriate, there is no obligation to provide it in the circumstances envisaged. You must explain your reasons and any other options that may be available to the patient, including their right to seeking a second opinion.
What is the basis of the discussion with a patient who is suitable for resuscitation but also lacks capacity?
If a patient lacks capacity to make a decision about future CPR, you must consult any legal proxy who has authority to make the decision for the patient unless it is not practicable or appropriate to do so. If there is no legal proxy with relevant authority, you must discuss the issue with those close to the patient and with the healthcare team. You must make all reasonable efforts to have these consultations or discussions at the earliest practicable opportunity and they should be approached with sensitivity. In your consultations or discussions, you must follow the decision-making model. In particular, you should be clear about the role that others are being asked to take in the decision-making process. If they do not have legal authority to make the decision, you should be clear that their role is to advise you and the healthcare team about the patient’s wishes and preferences to inform the decision about whether attempting CPR would be of overall benefit to the patient. You must not give them the impression that it is their responsibility to decide whether CPR will be of overall benefit to the patient, or that they are being asked to decide whether or not CPR will be attempted. You should provide any legal proxy and those close to the patient, with the same information about the nature of CPR and the burdens and risks for the patient.
What do you do if a patient’s legal proxy requests CPR but you do not think it is appropriate?
If the legal proxy requests that CPR is attempted, or if they are sure that this is what the patient would want, and it is your considered judgement that CPR would not be clinically appropriate, you must sensitively explore the reasons for their request, their understanding of what it would involve, and their expectations about the likely outcome. If after further discussion you still consider attempting CPR would not be clinically appropriate for the patient, there is no obligation to provide it in the circumstances envisaged. Explain your reasons and other options available such as their right to seek a second opinion.
Where should information about a DNACPR decision be documented?
Any discussions with a patient or those close to them about whether to attempt CPR and any decisions made, should be documented in the patient’s record and any advance care plan. If a DNACPR decision is made and there has been no discussion with the patient because they wanted to avoid it or if you thought the discussion would cause them serious harm, you should document this into their records.
Does a DNACPR decision apply at all times?
Not necessarily.
A DNACPR decision should not override your clinical judgement about CPR if the patient experiences cardiac or respiratory arrest from a potentially reversible cause that was neither discussed nor envisaged when the DNACPR decision was recorded. If a patient with a DNACPR decision in place has a planned procedure which could precipitate a cardiorespiratory arrest, such as an operation under general anaesthesia, there should be careful discussion with the patient (or with those close to a patient who lacks capacity) beforehand to reach agreement about possible temporary suspension of the DNACPR decision.
Should CPR be attempted if you are unsure of the patient’s resuscitation status during an emergency?
Emergencies can arise when there is no time to access all relevant information about the patient’s condition and the likely outcome of CPR; when no previous DNACPR decision is in place; and when it is not possible to find out the patient’s views. In these situations, CPR should be attempted, unless, in your clinical judgement it will not be successful.
