Policy responses and statements
- Name of organisation:
- The Scottish Government
- Name of policy document:
- NHS Scotland DNA CPR Policy - Draft for Consultation:
Integrated Policy on Do Not Attempt Cardio-Pulmonary Resuscitation
- Deadline for response:
- 26 February 2010
Background: Why is an integrated DNA CPR policy needed?
Cardio-pulmonary resuscitation (CPR) 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 cardio-pulmonary arrest represents the terminal event in their
illness and for whom CPR will not work 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 statement about treatment (such as CPR) that they would not
wish to receive in some future circumstances. These statements must
be respected as long as these 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 because the patient’s death has been without dignity,
traumatic and even painful. 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 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 “End
of life treatment and care: good practice in decisionmaking” 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 Cardio-Pulmonary Resuscitation (DNA CPR) decision-making and
communication.
Within this policy the term “Do Not Attempt Cardio-Pulmonary
Resuscitation” (DNA CPR) is used rather than “Do Not Attempt
Resuscitation” (DNAR) to help clarify for patients, families
and professionals that this policy refers solely to cardio-pulmonary
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 NHS
Scotland DNA CPR form, decision-making framework and patient information
leaflet, which can be found within and appended to this policy. The
purpose of the policy is to provide guidance and clarification for
all staff working within NHS Scotland regarding the process of making
and communicating DNA CPR decisions. 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. When no explicit
decision has been made about CPR before a cardio-pulmonary 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 not
work it should not be attempted, and experienced healthcare workers
who make this considered decision should be supported by their colleagues.
COMMENTS ON
THE SCOTTISH GOVERNMENT
NHS SCOTLAND DNA CPR POLICY - DRAFT FOR CONSULTATION:
INTEGRATED POLICY ON DO NOT ATTEMPT CARDIO-PULMONARY RESUSCITATION
The Royal College of Physicians of Edinburgh is pleased to respond to the
Scottish Government’s consultation on NHS Scotland DNA CPR Policy. This
response includes collated comments from Fellows working in the fields of Palliative
medicine, Acute and Critical Care medicine, and General and Elderly Care medicine.
STRUCTURE AND STYLE OF THE POLICY
The policy itself is written in an informal style, and there is a lot of duplication
and some ambiguity in consequence. The supporting documents were in some
cases clearer than the policy itself. Some paragraph headings appear
unnecessary. The disclaimer on page 18 seems extraordinary in the context
of a national policy. Such a statement might appear in a clinical guideline,
but for a policy document to say “nor should it be taken as advice” seems
contradictory. The Scottish Government should reconsider whether this
document is a policy or a guideline.
EXPERIENCE OF THE LOTHIAN GUIDELINE
As this guideline is based on the Lothian guideline, enquiries were made whether
any formal evaluation had been carried out. Only one limited audit with
questionable methodology and vague conclusions was identified. (It suggested
that “inappropriate resuscitations” are less likely to be performed
but no definitions were provided. No other outcomes have been evaluated.) No
patient or carer evaluations have taken place. No audit of the completeness
or accuracy of primary care or ambulance services documentation of the decisions
has taken place.
PRINCIPLES OF THE POLICY
There are important principles in this policy, some of which are more clearly
stated than others as indicated above. If these can be stated more clearly,
and in some cases expanded, the usefulness of the policy would be greatly enhanced.
1. Documentation of DNA CPR
All were agreed that clear documentation of DNA CPR decisions was useful. There
is concern that the policy for review of these decisions is less clear. It
is recognised that clinical situations vary, and hence a range of review times
is suggested, but it may be more useful to recommend a minimum frequency for
review, recognising that patient views on CPR may change. The retention
of photocopied forms or now invalid original forms (with lines scored through
them) in the case notes (page 9/10) will cause confusion. The use of photocopies
of the originals as valid forms (also page 9) will cause further confusion. Ideally,
only the original “red” form should be regarded as valid, and
no copies retained. The suggestion that ambulance crews can carry “written
confirmation that a DNA CPR form exists” will cause confusion, seems
counter to the principle of having a single document and requires clarification
with regard to the status of the signatory.
2. Separating DNA CPR from “other” resuscitation and treatments
The policy makes a laudable attempt to clarify this point, but concerns remain
that DNA CPR orders will have a negative effect on the other treatment of patients
in the hospital and the community. Anecdotal evidence in hospital suggests
that out-of-hours teams are less likely to search for and treat reversible
problems in the context of DNA CPR orders. More robust evidence to confirm
or refute this should be obtained by audit of the Lothian policy before national
implementation. It should be noted that the “arrest call” is
the quickest and most reliable means by which hospital staff can summon help
in the case of patient collapse. Lothian audit information confirms that
around half of patients in whom an arrest call has been made have not actually
had a cardio-respiratory arrest, but have collapsed and require more medical
support than is immediately available on the ward. Although the policy
stresses that the form only applies to CPR, in reality, in acute hospital practice,
the presence of a DNA CPR form is taken as the equivalent of “do nothing”,
particularly by Hospital at Night teams cross-covering large numbers of beds
and attempting to prioritise input. As frail, elderly patients are most
likely to have such forms completed, they are therefore potentially disadvantaged
in the event of sudden deterioration in hospital. This problem does not
just apply in hospital settings, but will also impact on patients in the community. A
quote from the National Audit Office End of Life Care report illustrates this. “DNR
orders are not being communicated to all the multiple agencies involved in
care, leading to inappropriate hospital admissions.” This
is an alarming statement that implies that the presence of a DNA CPR form can
be taken as meaning that a patient should not be hospitalised in the event
of acute illness. A single form, designed to cover a single decision,
cannot substitute for individual patient assessment.
3. Status of relatives’ opinions
One point well made is that relatives/carers cannot contribute to decision
making unless they have been appointed as welfare attorney. This is an
important learning point for staff who may have heard reports of relatives
angered by being unaware of DNAR orders.
4. Patient capability in decision making
As in other areas of healthcare, making an “informed “decision
is dependent on the quality and accuracy of information given, together with
other influences on the patient. It should be recognised, therefore,
that the patient may have a very different concept of what is “realistic” than
the doctor. When it comes to life or death, many people are prepared
to opt for even the slimmest chance of survival and dismiss all potential adverse
effects of an attempt at resuscitation. Patients may wish, therefore,
to discuss possible resuscitation when the policy says that there is no need
for the doctor to do so, or to offer such treatment. This leads on to
the consideration of definitions of futility, which is the weakest part of
this policy (see below).
5. No need to discuss decisions with patient where treatment would
not be offered
This is seen as a helpful principle in cases where it is clear that CPR will
not work. However there seems to be some inconsistency of ethics in non disclosure
in hospital, but a requirement for disclosure in the community.
6. The concept and definition of futility
The weakest part of this policy is the failure to address in more detail the
definition and concept of futility. Various terms such as “futile”, “realistic”, “inappropriate”, “certainty”, “untreatable”,
and “ineffective” are used interchangeably in the document without
clear definition. Futility is an important ethical principle. Absolute
futility is relatively rare and, in most cases, the question is one of “quantitative
futility” ie how likely is it that the particular treatment, in this
case CPR, will restore life? Useful and verifiable information on this
subject from research studies is patchy at best, some studies dating back to
the early 60’s. The location of the event and availability of a
prompt response is an important factor, together with the underlying cause. Successful
resuscitation is therefore more likely in coronary care than at home, and following
ischaemic VF arrest rather than severe pneumonia. Even experienced clinicians
will have difficulty in estimating the odds of success in a particular situation
and, as noted above, patients may wish to accept a lower chance of success
than clinicians. A single decision not to resuscitate is unlikely to
apply in all clinical settings, therefore, and a decision taken by one clinical
team, for example in hospital, might be viewed quite differently in the community. The
availability of ventilatory support is another factor that impacts on this
decision, and has consequences for remote and rural units in particular. The
policy has been authored by doctors with experience in traditional palliative
care, dealing predominantly with patients with cancer, in whom end of life
illness trajectories and predicted life expectancies are often clearer. This
policy is best suited to this patient group, but problems arise when it is
applied more widely to patients with a variety of pathologies in whom illness
trajectory and the anticipation of death is much more difficult.
7. Qualitative futility
The other aspect of futility is the qualitative one ie is it worth doing? The
policy makes clear that medical staff should concern themselves with medical
decisions (ie will it work?), and not consider qualitative aspects of the situation
which should be left to the patient and carers, if so appointed, or if they
are aware of the patient’s view. This is intended to remove bias
from the clinician, but seems at odds with the concept of holistic medicine,
which is integral to palliative care. One of the three categories of
DNA CPR, is that “the likely outcome of successful CPR would not be of
overall benefit to the patient”
This is a qualitative judgement, and in the context of a patient who lacks
capacity, or proxy, and who has given no indication of their wishes in life
to any family member, rests with the clinician. This is an all too common
situation in elderly care, and if the policy is applied as stands, could result
in exactly the sort of “inappropriate” resuscitation the policy
seeks to avoid.
CPR IN THE ABSENCE OF A DNA CPR ORDER
There remains ambiguity within the policy of what should be done in the event
of cardio-respiratory arrest in the absence of a DNA CPR order. Experienced
staff present should be “supported” in whatever decision they reach. A
positive policy on when CPR will be attempted, particularly in the community,
could be simpler and avoid many undignified deaths. Rather than a presumption
that CPR will be attempted, the policy might, for example, give instructions
for medical and paramedical professionals in the community to the effect that
CPR is not commenced by them unless the arrest/collapse is witnessed and CPR
is commenced within 5 minutes. The chances of survival in other circumstances
out of hospital are virtually nil. Such a directive would to a large
extent sort out the particular issue of inappropriate out of hospital resuscitation.
POLICY IMPLEMENTATION
As noted in the sections on futility, above, the availability and response
time of resuscitation teams and, in the community, ambulance staff will have
a huge bearing on likely outcome of resuscitation efforts. A single policy
is therefore unlikely to be applicable to all care settings.
If this policy is to be implemented, it will need to form part of resuscitation
guidelines drawn up by local boards and should not be implemented on its own.
The withdrawal of previous paperwork and guidance will be important. The
coexistence of two systems in Lothian has caused considerable confusion and
uncertainty and led to unnecessary communication problems as a result of DNAR
decisions being made on patients in whom there was a very low probability of
arrest during their hospital stay.
Educational materials to support this policy will be essential, and the resources
needed to change attitudes and knowledge of this topic across the whole healthcare
system should not be underestimated.
REVIEW OF RESEARCH
The research base on outcome after resuscitation in different healthcare settings
should be reviewed and form the basis of more definite guidance to clinicians
on the formation and practice of resuscitation teams, and the clinical circumstances
in which DNA CPR should be considered. Such a review might also highlight
the need for further research and audit of existing modern systems of care.
SPECIFIC COMMENTS ON TEXT
Our reviewers made some specific comments on the text of the document.
- CHILDREN (p.12, para 1): “The parent must give his/her consent
when a DNA CPR order is activated or rescinded. However, some children
of younger age … may be deemed competent to express their own view …”. Younger
than what? If deemed competent, does this mean that the preceding sentence
does not apply, and should read ‘parent should usually give consent
unless the child is able to do so’?
- APPENDIX II (p.22): Is there an error in the middle of p.22? Should
the 4th heading in bold read, “The patient who lacks capacity
to make a decision about resuscitation”? The bullet point below
suggests this, as it refers to a proxy decision-maker. It should also
be added that this person should only be involved if the clinician believes
CPR should be offered and yet wishes to give the proxy the opportunity to
decline CPR on the patient’s behalf.
- Appendix III (p.7 of patient information leaflet): Following the
question “What if I want CPR to be attempted, but my doctor says it
won’t work?”, the explanation begins “If it is certain
that CPR would not be successful in restarting your heart or breathing …”.
Certainty over this may be very difficult in many cases. The clinician
might think it very unlikely that circulation would be restarted
and the patient discharged home, but this might be a chance that the patient
would be willing to take.
- There may be circumstances in which the professional would discuss a clinical
decision not to offer CPR and the importance of having the form in more detail
with a family when it might be judged distressing to seek consent for that
decision with the patient (p.7).
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[25 February 2010]
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