The primary goal of healthcare is to benefit patients, by restoring or maintaining their health, and cardio-pulmonary resuscitation (CPR) is a prime example of a potentially life-saving intervention. However, whilst patients who have an acute event, such as a heart attack, may recover with CPR, the chances of survival are much lower for patients who suffer this due to the progression of a life limiting illness.
As such, a regional unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form, policy and patient information leaflet for use in all care settings has been developed. The policy carries a clear message that it is related to cardiopulmonary resuscitation only, for adults aged 18 and over. This ensures patients known to be approaching the end of life receive appropriate care and treatment, and are not resuscitated inappropriately or against their wishes.
These FAQs intended to answer some of the frequently asked questions around the implementation of the unified DNACPR policy in the North West region.
If someone’s heart or breathing stops as expected due to their medical condition and they have a DNACPR order, no attempt should be made to perform cardiopulmonary resuscitation (CPR).
Any DNACPR decision does not mean “Do Not Treat”. This should not affect other aspects of care and treatment should continue to be given; for example treatment of life threatening anaphylaxis, choking, infection, nutrition or hydration.
There is always a clinical judgment to be made at the time of a cardiopulmonary arrest. Where the arrest is witnessed and it is clearly due to an easily reversible cause it may be appropriate to initiate CPR irrespective of the DNACPR order, e.g. choking. This should, if appropriate, be explained to the patient at the time of making a DNACPR decision.
Not all care providers have adopted the unified policy and form.
For those Trusts who have adopted the uDNACPR policy the form is transferrable between settings, including during transport.
GPs in Primary Care and senior doctors and Consultants in Acute/Mental Health Trust or Hospice settings can sign the form.
Consultants/General Practitioners/Doctors making DNACPR decisions must:
- be competent to make the decision
- verify any decision made by a delegated professional at the earliest opportunity
- ensure the decision is documented
- involve the individual, following best practice guidelines when making a decision and, if appropriate, involve relevant others in the discussion
- communicate the decision to other health and social care providers
- review the decision if necessary
Yes each locality has supported the dissemination of information into their care home sector. The care home settings have adopted the form and have received support in the form of information and an education package delivered locally.
The regional DNACPR process is based on good communication practice and DNACPR decisions should be discussed with relatives where appropriate provided the patient has given consent.
This decision will be regarded as ongoing unless:
- A definite review date is specified
- There are improvements in the person’s condition
- Their expressed wishes change where a 1b & 1c (form section) decision is concerned.
All DNACPR decisions are subject to ongoing monitoring to ensure they remain appropriate; it is recommended that a review date be considered and entered on the DNACPR form if appropriate. It is important to note that a review date does not equate to an expiry date for ongoing decisions and remains clinically appropriate and valid.
It is still valid.
It is important to note that a review date does not equate to an expiry date for ongoing decisions and remains clinically appropriate and valid. All reviews should be documented in the patient’s records. Reassessing the decision regularly does not mean burdening the patient and their family with repeated decisions, but it does require staff to be sensitive in picking up any change of views during discussions with the patient or their family.
They can revoke an Advance Decision to Refuse Treatment (ADRT) but this does not mean that CPR would necessarily be appropriate for that patient and decisions would be made by the doctor on the basis of the patient’s medical condition.
DNACPR is a medical decision and a patient cannot demand clinically inappropriate treatment.
Each area has their own criteria for who has responsibility for making the DNACPR decision. Most have restricted this to Consultants, senior doctors and GPs.
Yes - as long as the senior clinician who takes over clinical responsibility for the patient in the new care setting is informed of, and is happy to take responsibility for the DNACPR decision as appropriate to their clinical assessment. This responsibility also involves an undertaking to review the decision, if appropriate.
The lilac copy of the form is the only valid copy held by the patient. Any other copies are for audit and medical records. These can be photocopied but must be scored through and "COPY" written across
A photocopy cannot be used as a valid form, only the lilac copy.
The form is completed in triplicate. The lilac copy is retained by the patient and is the only valid copy; one white copy should be kept for audit and the 2nd white copy should be retained in the patients’ notes.
NB: the newer version of the form has a lilac band down the right margin of the white audit copy to ensure this is easily identifiable.
If the form is printed electronically the valid patient copy should be printed on lilac paper with the 2 copies for audit and case notes printed on white paper.
An entirely new form should be completed by the patients’ doctor.
Any patient who deteriorates unexpectedly should be assessed and managed appropriately, regardless of whether there is a DNACPR form or not. This may involve calling 999 or putting out an arrest call in hospital to summon rapid medical assistance if that is appropriate. The decision not to attempt the procedure of cardio-pulmonary resuscitation detailed on the form does not preclude other interventions in situations other than a cardiopulmonary arrest but it may prompt different questions to be asked about what is happening to the patient (eg respiratory arrest).
It is the responsibility of the person completing the DNACPR form to ensure that the ambulance service is aware of the DNACPR decision by notifying North West Ambulance Service (NWAS) using the web based Electronic Referral & Information Sharing IT System (ERISS) or Electronic Palliative Care Coordination System (EPaCCs), whichever is available and in use. It is the individual’s responsibility to know what guidance is in place in your organisation for the information sharing process.
ERISS is the North West Ambulance Service’s Electronic Referral & Information Sharing IT System that will inform NWAS if a patient at an address has an order in place. It is a web based system and can be registered with and logged into by individuals (much like internet banking). Once a registration is set up an individual can enter patient details to the system, which in turn will flag up on the NWAS system when an ambulance is called to that address.
If the patient is taken to A&E via ambulance the paramedics will know, via the Electronic Referral and Information System (ERISS), which will flag up a patient at that address.
The paramedic should be able to access the form at the address and will inform the staff on arrival at A&E that the patient has a DNACPR in place.
It is the responsibility of the patient and/or carers to have the lilac form in an accessible location and this should be discussed with them so they are aware of their responsibility.
If the patient presents themselves at A&E it is the patient and/or carers responsibility to take the form with the patient and present to the A&E staff.
The decision belongs to the patient therefore it needs to be where the patient is. If the form is in the notes it will not be easily accessible to all health care professional looking after that patient at home. The patient will decide where to keep the form at home, whether this is in their care notes in the house, or in a drawer etc. and this will be highlighted on the DNACPR form at the time of completion on a tear off slip that can be kept in an easily accessible place.
Cross the old form with 2 diagonal lines and write clearly between the lines ‘Transferred to new documentation’ once the new form is complete.
If the patient is asking for this decision and is competent to make the decision their wishes should be respected. If it is refused, they are within their rights to seek a second opinion; the patient can ask for a second opinion to be sought from another consultant / GP.
It is the responsibility of the person completing the DNACPR form to ensure that other healthcare teams involved in the care of the patient are aware of the DNACPR decision.
This may be done electronically, verbally, by discharge letter or by safe fax.
It is the patient’s responsibility to tell other family members, friends and carers. However, it is good practice to discuss the decision with family members and this should be encouraged.
Please ensure that all health and social care staff who have been informed, are aware of their responsibility to document the decision in their own records, as the original stays with the person.
Within the policy it states that:
Current discharge letters must include information regarding this decision. If the DNACPR decision has a review date it is mandatory that the discharging doctor speaks to the GP to inform them of the need for a review. This should be followed up with a discharge letter.
In some areas some specialist nurses have training in making DNACPR decisions but this does not happen in every area. Within North West Borough Healthcare inpatient areas there are no specialist nurses who are trained to write a DNACPR decision. Within community this is an area that is currently being investigated.
Take the patient to a private room, ensure their hearing aids are working, someone who signs, if necessary, and their relevant others. The patient information leaflet is an adjunct to the discussions.
In these circumstances a translator can be used to facilitate discussions with the patient.
On discussion with the patient, or their advocate, should there have been changes to the patient’s health then the consultant can discuss this with the patient. This may lead to a decision for the form to be cancelled.
If the patients clinical situation or own decision has not changed there would be no reason to cancel the DNACPR decision. Having a different doctor in charge of a patients care should not be a reason to cancel.
All DNACPR decisions should be underpinned by the Mental Capacity Act. The form should be completed by the decision maker identified within the policy.
The new policy and form will be implemented on the agreed date within each area and you will need to use the form from this date onwards.
Any old forms were not recognised outside of the patient’s current setting and therefore would not have been valid as a unified form. The value of a unified form is that it will be recognised by the paramedics. Any old forms should be shredded or put in confidential waste bins.
Yes. It is important that the patient has information around the DNACPR decision in case they wish to refer to this after the discussion. It is also helpful for them to share with family and friends should they wish.
If you run out of hard copies of the leaflet, you can print a copy, although this should rarely occur as there is one patient leaflet per form in the packs supplied or purchased. The leaflet may only need to be printed if you are printing your forms electronically.
If it is a small error a single line cross out with signed and dated acknowledgement is sufficient.
If the form needs to be rewritten, cross the form with 2 diagonal lines and write clearly between the lines ‘Void due to error,’ do not discard as it is important for audit.
If you have a query regarding the policy or form you can contact your local lead or Resus Officer.
NWAS have requested we promote the use of ERISS as the preferred information sharing system.