Do not attempt cardiopulmonary resuscitation' decisions ... - Medicine

ETHICS AND COMMUNICATION SKILLS

Discussing ‘Do not attempt cardiopulmonary resuscitation’ decisions with patients

Key points C

‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions involve only intervention with CPR and not any other medical interventions

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DNACPR discussions are difficult and should take into account human factors on both the patient’s and the clinician’s side. Good communication skills, use of open questions and contextualizing ‘Allow natural death’ decisions are all important parts of this. They require time, training and good listening skills. First and foremost, they should be entered into with utmost sensitivity and respect

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To enable appropriate discussions, medical teams should identify patients who are at risk of a cardiac arrest and unlikely to benefit from CPR

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DNACPR discussions should be carried out by a knowledgeable, skilled and trained team member. This does not have to be a doctor. However, the senior responsible clinician should countersign the form

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The ‘treatment ladder’ approach is an example of how to discuss treatment interventions such as CPR without making patients feel that all other possible treatments are no longer on offer

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DNACPR decisions should be discussed openly. They should not take place when it is judged that doing so is likely to cause the patient significant harm. In this situation, the decisionmaking process must be clearly documented in the medical notes

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DNACPR decisions should be documented on the correct form according to local policies, and countersigned by the senior clinician responsible for that person’s care

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When there is a disagreement regarding a DNACPR decision, it is best practice to seek a second opinion from another senior clinician independent from the patient’s care. Patient liaison services and the Trust’s legal teams can be useful

James C Grose Mark Taubert Paul Buss

Abstract ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions have received a significant amount of attention, in part because of a highly publicized judgement from the Court of Appeal for England and Wales. Updated guidance from professional bodies and a public consultation on the English Emergency Care and Treatment Plan have sparked further debate. This article summarizes some of the key points for clinicians when making DNACPR decisions, including when and how DNACPR discussions should take place. It also suggests examples and methods for how to approach conversations with patients and proxies.

Keywords Advance care planning; ‘Do not attempt cardiopulmonary resuscitation’; resuscitation decisions

Introduction I think the best physician is the one who has the providence to tell to the patients according to his knowledge the present situation, what has happened before, and what is going to happen in the future. (Hippocrates)

James C Grose MRCP(UK) PgDip Palliative Medicine PgCert Medical Education is Palliative Medicine Registrar at the University Hospital of Wales, Cardiff, UK. Competing interests: none declared.

For practising clinicians, the process of anticipating whether a patient should undergo cardiopulmonary resuscitation (CPR) should this become necessary, and the discussions involved in such decisions, are strewn with challenges. First, it is important to understand wording and definitions in relation to ‘Do not attempt CPR’ (DNACPR) decisions.

Mark Taubert FRCP MRCGP MSc is Consultant Physician and Clinical Director for Palliative Medicine, Velindre NHS Trust, Cardiff, UK. Dr Taubert works as a consultant in palliative medicine in a cancer centre and on a university health board. He has a steady teaching commitment and is interested in research areas such as analgesia, out-of-hours work and how social media and medicine can interact successfully. Competing interests: none declared.

Definitions1

Paul Buss MB BCh MSc MRCP(UK) FRCPCh has been employed as a paediatrician for 30 years and has occupied clinical leadership roles since 2002 including Former Chair of the All Wales Medicines Strategy Group and Current Chair of the All Wales Procurement Group. He is Chair of the All Wales DNACPR Working Group and currently Executive Medical Director of Aneurin Bevan University Health Board, Newport, Wales, UK. Competing interests: none declared.

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Cardiac arrest, also known as cardiopulmonary arrest or circulatory arrest, is a sudden stop in effective blood circulation resulting from a failure of the heart to contract effectively or at all. CPR is a medical intervention that aims to restart spontaneous circulation and respiration. It is delivered with the specific intention of restoring and maintaining circulation and breathing.

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there is no need to discuss CPR. In this situation, should the patient suffer an unexpected sudden decline and cardiac arrest, CPR is likely to be a valid option in the decision pathway.5 However, some patients are at more significant risk of decline and cardiac arrest. They include those diagnosed with incurable, palliative conditions such as metastatic malignancy, chronic advanced cardiac or respiratory failure, those with multiple system co-morbidities and those not responding to acute treatments. For such patients, it is important to decide whether or not CPR should form part of future care.5 Scoring systems such as GO-FAR can help provide doctors with numerical data to share in terms of the likelihood of both survival and long-term deficits, but this is not currently widely used. If there is clinical evidence that CPR is likely to be futile or that resulting harm would outweigh potential benefits, or if a patient refuses CPR treatment, a decision should be made and documented along with the communication with the patient and proxy, both as part of the clinical notes and on a DNACPR form. The patient and/or proxy should, unless this is likely to cause psychological harm, be told that this decision has been made and entered into the notes. Where a decision has been made that CPR should not be attempted, this should form part of advance care planning discussions. Conversations should ideally be held when the patient is stable and in a position to process information and follow the decision-making processes that led the doctor and team to consider the CPR and DNACPR options. It is essential to help the patient in any way possible to gain a full understanding of the situation, this can include supplementing conversations with other material for example patient information leaflets or videos. It is also important to assess mental capacity and to establish the need for best interest decisions, proxy decision-makers and the presence of existing advance care planning documentation.

CPR is a physical and relatively invasive process. It usually comprises chest compressions to ventilate the lungs, possibly defibrillation by electric shocks and the injection of medication. DNACPR decisions are clinical decisions that have been made in advance of a situation in which a cardiac arrest might occur. Should a patient have a cardiac arrest, the form makes clear that the specific intervention of CPR should not be initiated. The authors have steered clear of the often used definition ‘DNAR’ (‘Do not attempt resuscitation’) as the term resuscitation can involve a plethora of other procedures apart from CPR, such as giving emergency fluids, antibiotics, glucose and blood products. These decisions also sometimes go by the name of ‘Allow natural death’ or ‘Allow natural and anticipated death’ orders.2 In this summary report, the authors have not discussed implantable cardioverter defibrillator devices; guidance on this issue can be found in the All Wales DNACPR policy (see Further reading).

Why is it important to consider DNACPR decisions? A key part of clinical medicine is ensuring that patients are given only those interventions that are likely to be beneficial. Doctors and nurses should be proficient in identifying patients for whom the act of CPR is likely to be futile and be able to have discussions relating to this with both patients and their proxies. Failure to do this results in a default position of exposing some patients inappropriately to the intervention of CPR, which can have significant and harmful adverse effects and can lead to a patient dying in an undignified and traumatic manner.3 Furthermore, a DNACPR decision can contribute to an approach through which a patient’s preferred place of care at the end of life is achieved, and can help prevent unwanted emergency hospital admissions.3

The case of Tracey v. Cambridge University Hospital4 In this high-profile court case, the judges ruled that failing to discuss a DNACPR decision with a patient who has capacity and expresses a wish to be involved in decision-making is a breech of their human rights under Article 8 of the European Convention. While stating that a clinician has a duty to discuss a DNACPR decision with the patient, the judgement also recognizes that there can be some situations in which having such discussions would be inappropriate. The judgement acknowledges that discussing DNACPR decisions with patients can cause distress, but distress on its own is not a valid reason to prevent such discussions from taking place. The only reason not to have the discussion is if it is believed that it will cause harm to do so. While the judges dismissed an argument that the European Convention required the Health Secretary for England to issue national guidance on DNACPR orders, Lord Dyson, Master of the Rolls, stated that there needed to be convincing reasons not to include a patient in such a decision. A summary of the ruling can be found in the UK Resuscitation Council guidance in the Further reading list.

Communicating DNACPR as part of a treatment pathway For patients in hospital, a useful trigger to initiate a DNACPR conversation can be a discussion about the reasons for admission and potential future treatment pathways and options. Would they want treatment X, Y or Z, and if they do not want one or more of these, why not? Clinicians may want to talk patients through a list of potential treatments and investigations that may be offered during an admission and ask them their views on each one, in particular in light of possible adverse effects. CPR can form part of this consent discussion. This approach ensures that patients and proxies understand that not opting for one treatment (e.g. CPR) does not preclude them from others such as antibiotics, intravenous fluids or systemic anticancer treatments. In Wales, a treatment ladder approach is used as part of the Sharing and Involving DNACPR policy, and a video is available for healthcare professionals (www.talkcpr.wales; video no. 4: ‘Top Tips’). The healthcare professional takes the patient and/or proxy up the rungs of a metaphorical treatment ladder, asking with each treatment (blood transfusion, intravenous fluids, intravenous antibiotics, systemic anticancer treatments, bisphosphonates) whether or not they would want it if it were on offer. The option of CPR can be then discussed at the top end or rung of the ladder as one of the more extreme forms of treatment.

When should CPR status be considered? For patients with no triggers to suggest that the risk of cardiac arrest is significant or likely to occur in the foreseeable future,

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Decision-making framework Is cardiac or respiratory arrest a clear possibility for the patient?

It is not necessary to discuss CPR with the patient unless they express a wish to discuss it. No If a ‘Do not attempt CPR’ (DNACPR) decision is made on clear clinical grounds that CPR would not be successful there should be a presumption in favour of informing the patient of the decision and explaining the reason for it. Subject to appropriate respect for confidentiality those close to the patient should also be informed and offered an explanation.

Yes Is there a realistic chance that CPR could be successful?

No

Yes

If the decision is not accepted by the patient, their representative or those close to them, a second opinion should be offered.

Does the patient lack capacity AND have an advance decision OR have an appointed attorney, deputy or guardian?

Where the patient lacks capacity and has a welfare attorney or court-appointed deputy or guardian, this representative should be informed of the decision not to attempt CPR and the reasons for it as part of the ongoing discussion about the patient’s care.

Yes

If a patient has made an advance decision refusing CPR, and the criteria for applicability and validity are met, this must be respected. If an attorney, deputy or guardian has been appointed they should be consulted.

No

Yes

Discussion with those close to the patient must be used to guide a decision in the patient’s best interests. When the patient is a child or young person, those with parental responsibility should be involved in the decision where appropriate, unless the child objects.

No

Respect and document their wishes. Discussion with those close to the patient may be used to guide a decision in the patient’s best interests, unless confidentiality restrictions prevent this.

Does the patient lack capacity? No Is the patient willing to discuss his/her wishes regarding CPR? Yes The patient must be involved in deciding whether or not CPR will be attempted in the event of cardiorespiratory arrest.

• If cardiorespiratory arrest occurs in the absence of a recorded decision there should be an initial presumption in favour of attempting CPR. • Anticipatory decisions about CPR are an important part of high-quality healthcare for people at risk of death or cardiorespiratory arrest. • Decisions about CPR are sensitive and complex and should be undertaken by experienced members of the healthcare team with appropriate competence. • Decisions about CPR require sensitive and effective communication with patients and those close to patients. • Decisions about CPR must be documented fully and carefully. • Decisions should be reviewed with appropriate frequency and when circumstances change. • Advice should be sought if there is uncertainty.

Figure 1 A decision-making framework from Decisions Relating to Cardiopulmonary Resuscitation, BMA, Resuscitation Council (UK) and Royal College of Nursing, October 2014. Reproduced with the kind permission of the Resuscitation Council (UK).

knowledge and skills. In the hospital setting, this is likely to be a consultant or registrar, but it can also include more junior doctors and specialist nurses. Some staff members know the patient well and have seen them on a daily basis, and these discussions are best held where there is already a firm basis of trust, independent of hierarchy. If a patient decides they would like to ask a ward nurse, it would be a wasted opportunity if the nurse declined because they felt this sort of discussion must be held with a doctor.

Having heard and discussed all the other treatments available, some patients may feel reassured and confident enough to refuse CPR, in particular if they hear its adverse effects and extremely low success rates. Others may believe it is still something they would ask to be considered by the medical team.

Who should discuss DNACPR decisions? As with any discussion in clinical practice, this should take place with a healthcare professional who has the appropriate level of

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with the patient’s consent, that those close to the patient are informed of the decision at the earliest opportunity; however, this should not delay a decision being made in an emergency situation. The Mental Capacity Act 2005 Code of Practice is a key document that outlines the role of Court-appointed deputies and independent mental health advocates e individuals who, when appointed, should be consulted when decisions are being made that involve an individual lacking the capacity to be involved in the decision-making process.

It is also important that the decision to initiate a DNACPR order is discussed in agreement with the senior clinician who takes overall responsibility for that patient’s care. In the community this is the general practitioner, and in hospital it is usually the consultant leading the clinical team. The overseeing clinician should also sign or countersign the DNACPR document on which the decision is recorded. He or she may not have held the discussion with the patient or proxy but should have discussed this with the person who has. The person discussing this with the patient should always consider that this is likely to be one of the most challenging discussions a patient has had to face in their healthcare journey, and should remember the human elements involved in having these discussions.

The difficulty with DNACPR policy approaches It should be acknowledged that policies relating to DNACPR are created in a moving field of ethical, legal, societal and moral challenges. Medical advances and social and cultural dimensions of attitudes that are shifting in relation to end-of-life decisions must be considered and not dismissed. An awareness of this element will allow practising clinicians to maintain excellent practice in this field. A

General principles and recent updates in approaching the discussion of resuscitation It is a clinician’s duty to discuss with patients who have capacity and, if the patient gives permission, those close to them when DNACPR decisions are being made and placed in the medical notes. In doing so, it is recognized that there is the potential for discussions to be distressing. This is, however, not in itself a reason to prevent a conversation taking place, as was made explicit by the Court of Appeal ruling. If the decision is made not to discuss a DNACPR decision with a patient because doing so is likely to cause the patient psychological harm, the reasons for this must be clearly documented, ideally in the notes but also on the DNACPR form itself.4 When discussing DNACPR decisions with patients and proxies, language and communication needs must be considered and addressed. The situation should be approached sensitively and with openness to enable trust and ensure that the patient remains the centre of the discussion.1 Figure 1 outlines a useful framework that can be used to approach decisions regarding resuscitation.

KEY REFERENCES 1 Buss P, Finlay I, Saunders J, et al. Sharing and involving e a clinical policy for do not attempt cardiopulmonary resuscitation (DNACPR) for adults in Wales. 2015 (accessed 9 Feb 2016), www. wales.nhs.uk/sitesplus/866/opendoc/252961. 2 Venneman S, Narnor-Harris P, Perish M, Hamilton M. ‘Allow natural death’ versus ‘do not resuscitate’: three words that can change a life. J Med Ethics 2008; 34: 2e6. 3 General Medical Council. Treatment and care towards the end of life: good practice in decision making. 2010 (accessed 9 Feb 2016), http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_ care.asp. 4 Royal Courts of Justice. Between the queen on the application of David Tracey (personally and on behalf of the estate of Janet Tracey (deceased)) and Cambridge University Hospital NHS Foundation Trust and others. 2014 (accessed 7 Mar 2016), https:// www.judiciary.gov.uk/wp-content/uploads/2014/06/traceyapproved.pdf. 5 British Medical Association, Resuscitation Council (UK) and Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation. 3rd edn. 2014 (accessed 9 Feb 2016), https://www.resus. org.uk/dnacpr/decisions-relating-to-cpr/.

Challenging situations Clinicians sometimes find themselves in a situation where they judge that CPR should not be attempted but the patient has difficulties accepting this decision and requests that CPR is performed despite this medical opinion. In this scenario, it is important to gain a second opinion and to be aware that if a clinician considers CPR to be a futile intervention, the patient cannot demand CPR.4 Therefore, when a patient makes a request for ‘full CPR’ that is clearly contrary to the unanimous judgement of the clinical team, this should be urgently reconsidered by the clinical team and an attempt made to reconcile the position. If a second senior clinical opinion has been sought and the challenge is upheld, patient liaison services may help. Legal advice may be necessary; hospitals and primary care services have legal representatives who can provide help and next steps. All such cases should be subject to reflection at a later significant event audit to facilitate team and organizational learning. When a patient lacks the capacity to be involved in a resuscitation conversation and CPR is deemed not to be beneficial, it is necessary to consult an appointed attorney, deputy or guardian in discussions and decision-making, if such individuals are available or have been identified.5 It is also good practice,

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FURTHER READING For a concise summary of the clinical implications of the Tracey judgement, see the Resuscitation Council (UK)’s summary statement at https://www.resus.org.uk/dnacpr/tracey-v-cuh-andsecretary-of-state-for-health/. In addition to these national guidelines, the British Medical Association, Resuscitation Council (UK) and Royal College of Nursing published guidance in October 2014 entitled ‘Decisions relating to cardiopulmonary resuscitation’ (3rd edn), which can be assessed at https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/. More detailed information on clinical decision-making for those individuals who lack capacity can be found in the Mental Capacity Act 2005 Code of Practice at https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/497253/Mentalcapacity-act-code-of-practice.pdf.

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National guidance on making DNACPR decisions are in place in both Wales and Scotland. In Wales, the policy is entitled ‘Sharing and involving: a clinical policy for DNACPR for adults in Wales’ and it can be accessed at www.wales.nhs.uk/sitesplus/866/opendoc/ 252961.

The national guidance in Scotland, published in May 2010, is entitled ‘Do not attempt cardiopulmonary resuscitation (DNACPR): Integrated adult policy’ and can be accessed at http://www.gov.scot/ resource/doc/312784/0098903.pdf.

TEST YOURSELF To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the end of the issue or online here.

Question 1

In this situation, how should the clinical team best proceed? A. Tell the patient that their opinion will be documented but that the decision to initiate CPR is a medical one and there is no obligation to perform interventions that are likely to be futile B. Apologize to the patient and withdraw the DNACPR decision C. Ask the family (away from the patient) to persuade the patient that this is what is best D. Inform the patient that the clinical team will think about the decision and meanwhile keep the DNACPR active E. Inform the patient that a second opinion will be sought from a senior medical doctor and that the patient will be kept updated

A 78-year-old man with chronic obstructive pulmonary disease was admitted to hospital with severe community-acquired pneumonia. Despite 5 days of active ward-based management with intravenous fluids and antibiotics, it became evident that he was not responding. His medical team made the decision to withdraw treatment and felt that cardiopulmonary resuscitation (CPR) would not be beneficial or successful in his situation. What would now be the most appropriate action? A. This decision must now be discussed with the patient and their family B. The family should be made aware of this decision, and then it will not be necessary to involve the patient C. The patient should be made aware of the decision and should tell the family if he wishes D. The decision should be discussed with the patient (unless harm is considered likely) and with the relatives (with consent) E. No further discussion is necessary because the medical team agrees that CPR is futile

Question 3 A ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decision needed to be recorded in the hospital notes. How would this best be done? A. The decision needs to be documented in the main body of the medical notes B. The decision should be recorded on a designated form and countersigned by the senior clinician responsible for that patient’s care C. The decision should be recorded on a designated form and countersigned by a member of the multidisciplinary team D. The decision must be discussed with the patient’s general practitioner and the discussion recorded E. The patient (or a proxy if capacity is lacking) should also sign the record

Question 2 A 67-year-old man had type 2 respiratory failure from chronic obstructive lung disease. This had not been responding to treatment and the clinical team had decided to discuss a ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decision with the patient. The patient made it very clear that he disagreed with the decision and demanded that CPR should be performed if he had a cardiac arrest.

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