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DNACPR

Discussing resuscitation decisions

February 2016

DNACPR“My patient has just been admitted having collapsed at home. Their condition has rapidly declined and they are at risk of cardiac arrest. We now need to decide whether CPR should be attempted in those circumstances or a Do Not Attempt CPR order should be made.

Although CPR may be successful in restarting my patient’s heart and breathing, I don’t think it would be in the patient’s interests given their condition. They lack capacity to discuss the situation and make a decision about CPR. I want to discuss this with their daughter who is in the hospital and has made it clear that she wants everything possible to be done. How do I handle this?”

How to approach such sensitive discussions with patients and those close to them is one of the most frequent enquiries we receive. We know it is an incredibly emotive issue which can lead to conflict with family members and others close to the patient. People often don’t know what CPR actually involves or that it has a very low level of success in most cases, as they are heavily influenced by unrealistic television portrayals. Recent court judgements have highlighted the importance of involving patients and those close to them in discussions about making a DNACPR decision. It is vital that doctors feel confident and supported in meeting these responsibilities.

Here we go through some of the issues the doctor would need to consider in the above scenario, highlighting relevant GMC and other guidance.

 

Why do you think CPR is not in your patient’s interests?

1. Your patient is dying

If in this scenario cardiac arrest is an expected part of your patient’s dying process, you will want to consider how to support their daughter to absorb this news and come to terms with the situation. While you may have faced the death of a patient, as part of your everyday work, for the patient’s daughter this is likely to be a new and profoundly affecting situation.

Ideally your discussion about making a DNACPR order should happen within a wider discussion about the patient’s condition and the management of their future care, so the focus is not solely on what will not be done for the dying person. Given public concerns about how DNACPR decisions are made, it’s likely that the patient’s daughter will need strong reassurance that making a DNACPR order does not mean the patient will cease to receive a high standard of care. So you must be ready to explain how their care will be managed and monitored, and discuss how the daughter can play a part in providing that care and support, if she wishes to do so. You must involve the wider healthcare team in the decision making and the discussions with the patient’s daughter.

Clearly conversations about death and dying are challenging and distressing and may need to happen over time with information being repeated and provided in different ways to meet the needs of those close to the dying person. You should be aware of what support would be available to the patient’s daughter within the hospital, for example from the chaplaincy service and any patient/family support groups.

Given the potential for conflict to arise in discussions about DNACPR decisions, it’s important that you are clear with the patient’s daughter about her role in the decision making process. In this situation you are not asking her to decide whether CPR should be attempted but explaining the reasons for your decision not to attempt CPR when her parent is dying. If the patient’s daughter disagrees with your decision, it should be possible to resolve this with support, for example by involving the wider team and obtaining further input from an expert colleague. You must explain to your patient’s daughter that she has a right to seek a second opinion if she wishes to do so, and you should be aware of local processes for facilitating this.

2. On balance, the benefits are outweighed by the risks

If the situation is one where CPR may be successful, but in your view the likely burdens and risks for the patient outweigh the possible benefits of successful CPR; then your assessment of the best course of action for your patient will need to take account of your patient’s wishes and preferences. The goal is to decide whether in the circumstances attempting CPR would be of overall benefit to (in the best interests of) the patient.

Did your patient record any previous wishes about their future care?

As your patient lacks capacity to decide, you must explore whether they have a care plan that addresses the current situation or may have recorded their wishes in other ways. If there is nothing recorded in your patient’s medical records, check with the wider care team (including their GP) and with their daughter or others close to the patient.

If your patient has a written advance refusal of treatment, you will need to consider whether it is applicable to their current circumstances and would be seen as legally binding in the country where you practice. This is a difficult assessment to make and there is advice in Treatment in care towards the end of life (paragraphs 67) that you should find helpful.

If your patient has a made an advance request for treatment or has a non-binding advance refusal of treatment, this should be taken into account as evidence of their wishes and preferences.

If your patient’s wishes are not recorded, what should you do?

If your patient doesn’t have any recorded information about their wishes, you must check whether someone has been granted legal authority to make healthcare decisions on their behalf (a legal proxy). For example, in England, Wales and Scotland a patient may have granted a partner or someone else power of attorney, or the court may have appointed someone with power to make such decisions. (You can read more about legal proxies and relevant mental capacity laws and codes of practice in the legal annex to our guidance.)

If there is no legal proxy to make the decisions about care, you must discuss your patient’s situation with the patient’s daughter and the wider healthcare team to inform your decision about whether, in the circumstances, attempting CPR will be of overall benefit to the patient.

How do you discuss DNACPR with people close to your patient?

Bearing in mind ongoing patient and public concern about the way that DNACPR decisions are made; clear, honest and sensitive communication is essential. It reduces the possibility of misunderstandings as well as ensuring the decision considers not only the clinical factors, but also takes account of the patient’s wishes where known and any non-clinical factors that they may have seen as relevant in weighing up the benefits and harms.

People often have unrealistic expectations about the success rate of CPR; they may be poorly informed about what CPR involves and have little knowledge about the possibility of harmful outcomes. So it’s important to provide up to date information, for example making use of up to date patient/public leaflets and decision aids where available.

What if those close to your patient strongly disagree with your decision?

You should aim to reach a consensus about whether CPR would be of overall benefit for your patient. Most disagreements can be resolved using local processes including, for example, involving a patient advocate or seeking further advice from expert colleagues. In Scotland there is a statutory process for seeking a second opinion.

If, after discussion, your patient’s daughter or others close to the patient strongly disagree with your view that attempting CPR would not be of overall benefit to the patient, you are not obliged to attempt CPR against your clinical judgement. However, you must explain the reasons for your view and any other options that may be available to those close to the patient, such as seeking a second opinion and/or a ruling from the court.

For more GMC guidance on dealing with key challenges in DNACPR decision making, please read our cardiopulmonary resuscitation section of our guidance on the Treatment and care towards the end of life (pdf).