Heartbeat: DNACPR – a need to know

May 25, 2021

COVID-19 and pandemic working has highlighted good ways of working together for delivery of high quality and evolving care. However, a new report from the Care Quality Commission (CQC) found worrying variation across the NHS in do not attempt cardiopulmonary resuscitation (DNACPR) decisions during this period.

There were examples of good practice but also patients not properly involved in decisions, or unaware that such an important decision about their care had been made.

This article describes what we need to know and within SWB how this should be achieved.

COVID-19 pressure had an impact, including the time that colleagues had to hold meaningful conversations. A lack of training and large amount of rapidly changing guidance also presented significant barriers. Decisions concerning DNACPR were incorrectly combined with other clinical assessments regarding ongoing care.

Wherever patients are cared for, it is not acceptable for DNACPR decisions to be made without proper conversations with the individual, or an appropriate representative, taking into account their wishes and needs.

However, the issues raised in the CQC report; including limited understanding of the importance of good conversations around what should happen if someone was to become very ill, and the need for proper and consistent processes around this – pre-date the pandemic.

As highlighted by the CQC: “Personalised and compassionate advance care planning, including DNACPR decisions, is a vital part of good quality care. Done properly, it can offer reassurance and comfort for people and their loved ones – before and during difficult times.”

If a patient is admitted to hospital acutely unwell, and they are at foreseeable risk of cardiac or respiratory arrest, a judgement about the likely benefits, burdens and risks of CPR should be made as early as possible.

At SWB, we expect that an initial consideration is made, discussed and documented within 12 hours of admission (i.e. the initial consultant review after admission).

Some patients, with capacity to make their own decisions, may wish to refuse CPR.

We recognise that a consultant discussion often does take place at the time. Some decisions are recorded by our trainee doctors and for some, never signed off by the consultant in charge of care, in patients admitted for many days. This can lead to discharge problems (e.g. to medically fit for discharge wards). It also leaves non-consultant colleagues unsupported in the decision making process.

Cardiac arrest is an expected part of the dying process and when CPR will not be successful, a decision not to attempt it will help to ensure that the patient dies in a dignified and peaceful manner.

When the healthcare team is as certain as it can be that someone is dying, CPR should not be attempted.

We must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made but as made clear in high profile legal cases on this matter: “there should be a presumption in favour of patient involvement. There need to be convincing reasons not to involve the patient.”

Distress of the patient (or discomfort of the healthcare provider…) is not enough to justify withholding these discussions: the Court of Appeal acknowledged many patients may find this discussion distressing, but unless it would cause physical or psychological harm, this is not sufficient reason not to discuss it.

If a patient lacks capacity, we should inform others close to the patient about the DNACPR decision and the reasons for it. That explanation is expected to be at the earliest practicable and appropriate opportunity: this may well be in the middle of the night.

We must do this even when we think that CPR has no realistic prospect of success.

In cases when CPR might be successful (e.g. in restarting the heart) it might still not be seen as clinically appropriate because of the likely clinical outcomes (e.g. significant physical or cognitive problems afterwards).

Decisions about whether CPR should be attempted must be based on the circumstances and wishes of the patient.

This may involve discussions with the patient or with those close to them, or both, as well as members of the healthcare team.

If the patient has capacity, we should offer the patient opportunities to discuss (with support if they need it) whether CPR should be attempted in the circumstances that may surround a future cardiac or respiratory arrest. If they are prepared to talk about it, we must provide accurate information about burdens and risks, including the likely clinical and other outcomes if CPR is successful. This should include sensitive explanation of the extent to which other intensive treatments and procedures may not be seen as clinically appropriate after successful CPR. For example, support for multi-organ failure in an ICU may not be clinically appropriate even though the heart has restarted.

Some patients may wish to receive CPR when there is only a small chance of success, in spite of the risk of distressing clinical and other outcomes. If we consider that such an intervention is not clinically appropriate, we should ensure that they have accurate information and explore reasons for the request. Try to reach agreement: it may be that limited CPR interventions are acceptable to both patient and clinicians.

When the benefits, burdens and risks are finely balanced, the patient’s request will usually be the deciding factor.

If, after discussion, we still consider that CPR would not be clinically appropriate, we are not obliged to agree to attempt it in the circumstances envisaged and should explain our reasons and any other options that may be available to the patient, including seeking a second opinion.

Ensure that any discussions with a patient, or with those close to them, about whether to attempt CPR, and any decisions made, are well documented.

If a DNACPR decision is made and there has been no discussion with the patient because they indicated a wish to avoid it, or because it was your considered view that discussion with the patient was not appropriate, note this in the patient’s records.

These decisions require reassessment and ongoing documentation: Doctors Worklist, within Unity, is the agreed workflow. Medical teams are expected to use this to complete these reviews contemporaneously.

We must remember and be clear that a DNACPR decision applies only to CPR. It does not imply that other treatments will be withdrawn or withheld. For example, some patients come to ICU with a DNACPR order and go on to receive multiple organ support.