Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) discussion
Introduction
DNACPR discussions with patients and relatives are common both in the hospital and community setting. However, they still remain a great source of anxiety for many doctors.
They should be seen as no more than a natural progression of a larger discussion (see pages on breaking bad news for advice on this).
Preparation
It is important to familiarise yourself with the law regarding DNACPR which has changed following the Tracey judgement. The GMC Treatment and Care towards the End of Life document has very clear guidance on this.
The judgement in the case of Janet Tracey (brought to the court of Appeal by her husband David Tracey on her behalf) was published in June 2014.
Mrs Tracey had been diagnosed with lung cancer with an estimated life expectancy of 9 months on the 5th February 2011. On the 13th February, she was admitted to hospital with a serious cervical fracture secondary to a road traffic accident, following which her condition deteriorated requiring an admission to intensive care for respiratory support.
During this time a DNACPR order was put in place without discussion.
The DNACPR was reversed following expression of concern from her family. A few days later her condition deteriorated again and this time resuscitation was discussed with her family. A second DNACPR order was put in place and she died 3 days later.
The judgement ruled that by failing to discuss the initial DNACPR decision with Mrs Tracey (who had capacity and expressed clear wishes to be involved in all treatment discussions) the Trust were in breach of Mrs Tracey’s human rights.
What recommendations came from the Tracey Judgement?
Doctors should discuss all advanced DNACPR decisions with patients and those close to them as soon as possible unless there are exceptional circumstances
All DNACPR decisions should be discussed with the patient (if they have capacity) unless it is thought that this will cause physical and/or psychological harm.
Purely citing distress as a reason for not discussing resuscitation is not acceptable.
DNACPR decisions and reasons for these should be clearly documented in a timely fashion
All discussions with patients and those close to them should be clearly documented
Note that just because DNACPR must be discussed with the patient, this does not mean the patient has the right to insist on being resuscitated: the decision on whether to resuscitate lies with the medical team, acting in the best interests of the patient.
See below for guidance on how to conduct a DNACPR discussion
A capacity assessment should be completed if the person being assessed has ‘an impairment of, or a disturbance in the functioning of, the mind or brain’ which may affect their ability to make the decision in question.
A capacity assessment is decision specific.
The patient may have capacity for some decisions but not all
A person is deemed to lack capacity if, at the time of assessment, they cannot do any one of the following four points:
Understand the information given to them relevant to the decision
Retain the information given to them relevant to the decision
Weigh up the information in order to formulate a decision
Communicate the decision (by any means)
This is referred to as the four-stage test of capacity
Tip – The capacity assessment should always be documented clearly, including the reasons why capacity was being assessed.
How to have a DNACPR discussion
This will usually be part of a longer discussion about aims of treatment and ceilings of care.
It helps to have discussed treatment and prognosis generally with the patient and family prior to a DNACPR discussion so you have a better idea of what the patient’s wishes may: this will influence what is in their best interests.
Prior to a DNACPR discussion, ensure you have discussed amongst the team what you feel the ceilings of care should be and if and why the patient is likely not appropriate for CPR
Ceiling of care refers to how far would escalate treatment if the patient deteriorated. Think about:
If they would be for ITU, would they be a candidate for:
Ventilation?
Inotropes?
Haemofiltration?
If the above would not be appropriate, why not? (e.g. the patient would likely never get off the ventilator so it would not be in their best interests)
Once you have a clear idea of what you feel is appropriate:
Ask the patient and/or their relatives whether they had previously thought about the future/resuscitation or voiced any opinions on the subject (this can save you a lot of work!)
Remember you are not asking the patient or family to make a decision (this would be very unfair)
Instead, you are informing them of a clinical decision and the reasons for this (patients and relatives cannot demand a treatment).
There are many ways to do this. One way is:
Explain that you are providing all possible treatments to improve the patient’s condition/keep them comfortable.
The one thing you are trying to avoid is doing any harm. One of the things that may cause harm would be to aggressively try to restart their heart if it stopped. As such, that is not something you would do.
However, you will continue to give all other treatments, this only applies to what you would do if their heart stops.
Then pause. Let this information sink in and answer questions. This can be a very sensitive and emotive topic so it should be done gently and collaboratively.
If there are concerns, reassure (where appropriate) that the DNACPR form definitely does not mean that care is being withdrawn.
If there is disagreement between the patient or their family and the medical team, a full and detailed discussion should happen as soon as possible to examine the reasons for the discrepancy.
All discussions and reasoning should be documented in detail.
If the issue is difficult to resolve this should be escalated to consultant level as soon as possible.
If there is a disagreement regarding the decision, a second opinion can be sought.
Remember the DNACPR form is put in place to ensure that the patient continues to be treated with dignity and respect by providing appropriate medical care.
Follow up
Document any reasons for the DNACPR decision carefully in the patient’s notes.
Document all discussions with the patient and those close to them carefully.
If not present at the time of discussion, ensure that the consultant responsible for the patient counter-signs the form as soon as possible (within 24 hours).
