When and how should DNACPR decisions be made?

A blog Dr Arup Chakraborty for oxicm

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision-making ended up in the headlines last year when the Court of Appeal judged that Janet Tracey’s human rights had been breached when she had been made DNACPR without her knowledge. It can be an emotive topic and is often portrayed inaccurately in the media (Holby City etc).

Of those in whom CPR is attempted, the success rate (return of spontaneous circulation) is around 18% but in line with medical 
dramas, the general public’s perception is that it is much higher. Success at restarting the heart is almost always followed by a significant period in intensive care and is often associated with significantly reduced mental and physical function.

The Care Quality Commission looks in detail at DNACPR documentation during its inspections. This issue is of importance to clinicians, patients and the general public. I attended a symposium on the subject at the Royal Society of Medicine in October when best practice was discussed by both clinicians and lawyers.

The Tracey case is summarized.

She was a 63-year-old woman who had been in a major road traffic accident on 19th February 2011 and had sustained a cervical spine fracture which led to her being admitted to Addenbrooke’s hospital. She had been recently been diagnosed with inoperable lung cancer and been given a prognosis of 9 months. She deteriorated and was transferred to neuro ICU on 20th February for respiratory failure where she was intubated and ventilated and treated for pneumonia and malignant pleural effusion. She failed two extubations.
On 27th February, the ICU consultant made a first DNACPR order after discussion with an oncologist and Mrs. Tracey’s daughter. Mrs Tracey was still ventilated and not involved in the discussion. She was extubated on 28th February. On 2nd March, the DNACPR was cancelled after Mrs. Tracey’s daughter complained. She was transferred to the ward and reviewed by the Palliative care team. Around this time, Mrs. Tracey told her husband that she was being “badgered” about making a decision about resuscitation. The patient wanted any further discussion to be with her and her husband or one of her children present. On 5th March, a second DNACPR order was made. The patient did not wish to discuss resuscitation and the family was fully involved. All felt palliation was appropriate. Mrs Tracey died on 7th March.

There were two DNACPR decisions. Only the first was the subject of complaint.

At the relevant time the patient had the capacity to make decisions about her treatment and wanted to be involved in decisions. The DNACPR decision does not require clinicians to provide treatment they consider to be inappropriate but underlines the patient’s potential access to a second opinion.

The Resuscitation Council (UK), British Medical Association and Royal College of Nursing were in the process of reviewing and updating their guidance, but delayed publication until after the Tracey judgment. The guidance was previously known as the Joint Statement. The document:

·      emphasises the importance of making anticipatory decisions about CPR as an integral part of good clinical practice: leaving people in the ‘default’ position of receiving CPR should they die, regardless of their views and wishes, denies them of the opportunity to refuse treatment that for many may offer no benefit and that many may not want;
·      once again emphasises that every anticipatory decision about CPR must be based on assessment of the person’s individual circumstances at that time;
·      emphasises the importance of involving people (or their representatives if they are unable to make decisions for themselves) in the decision-making process; this often involves a person making a shared decision with their healthcare professionals, but where CPR has no realistic chance of success it may involve informing people of the decision and explaining the basis for it
·      emphasises that when CPR has no realistic chance of success it is important to make decisions when they are needed, and not to delay a decision because a person is not well enough to have it explained to them or because their family or other representatives are not available; nevertheless a clear plan should be made to explain and discuss the decision with the person and/or their representatives at the earliest practicable opportunity;
·      emphasises that, whenever possible, anticipatory decisions about CPR are best made well in advance, when people are well enough and have enough time to consider them carefully and discuss them fully with anyone that they wish to, including their family and members of their healthcare team;
·      emphasises the increasing recognition that such advance decisions are often best made as part of a broader consideration of the type of care or treatments a person would wish to receive (as well as the type of care or treatments they would not wish to receive) should their health deteriorate so that they are unable to make choices for themselves
·      emphasises the importance of careful documentation and effective communication of anticipatory decisions about CPR.

There is a legal obligation to consult where it is practical and appropriate to do so. If the patient has capacity and he/she has been consulted with, technically there is no further obligation to consult with their relatives.

Where the patient lacks capacity, the principles of the Mental Capacity Act (MCA) should be followed. Specifically those without capacity should have a best interests process initiated (Section 4 of the MCA).

If a patient lacks capacity but their relatives are present for consultation, the process should be straightforward. The process may be more complex when the patient lacks capacity and their relatives are not present. A frail patient with dementia and multiple comorbidities being admitted with sepsis out of hours and without relatives present, is a common occurrence. Pragmatically, it may be a more straightforward process to make an anticipatory DNACPR decision in these cases compared with those lacking capacity due to learning difficulties that are usually younger and less frail.

In an emergency, it is preferable to make an appropriate DNACPR decision in the absence of relatives than to let the patient receive futile CPR. Attempts should have been made to contact the next of kin. In more elective cases, it is preferable to make an appropriate anticipatory DNACPR decision in the absence of relatives but there should be a clear plan in the notes to explain/ discuss/ review decisions.

While an advanced decision can insist on DNACPR, it cannot insist on CPR occurring even if it is deemed futile. Consultees (patient, family, friends, carer, IMCA, Attorney under Lasting Power of Attorney) cannot demand treatment.

While the patient with capacity should be told about the DNACPR decision, they may not want to know or discuss it. Causing distress is not a reason to withhold the above but causing harm (physical or psychological) is. Reasons must be documented.

Consulting means involving or in many cases informing consultee(s) that a DNACPR decision has been made. It is a clinical decision to give CPR and other treatments. It should not be given if clinically inappropriate and not in the patient’s best interests. Where there is disagreement, a second opinion should be sought.

When should CPR decisions me made?

The National Confidential Enquiry into Patient Outcome
and Death (NCEPOD) report, Time to intervene?, suggested that resuscitation decisions should be explicitly recorded routinely on all acute admissions. If CPR discussions became routine and perhaps initiated in clinics, GP practices and nursing homes, the risks
 of attempting unwanted CPR would also be diminished: it is equally important to ensure that patients have the opportunity both to refuse CPR and to question a clinical decision.

Another perception is that the DNACPR decision transforms the doctor from ‘care provider’ to ‘care withholder’. One way of overcoming this is to ensure that CPR decisions are always contextualised within a broader plan of what treatments are to be given, rather than focusing on the one to be withheld. The introduction of Treatment Escalation Plans (TEP) and the Universal Form of Treatment Options (UFTO) in various trusts may facilitate this.

How should DNACPR decisions be made?

This of course is subjective. When I worked at a previous trust, I was involved in drawing up some guidelines along with two geriatricians and an anaesthetic intensivist. I am a medical intensivist.  While the presence of one of these criteria is not in itself an absolute indication for making a DNAR decision, the presence of two or more criteria should prompt one to at least consider an assessment.  The more of these criteria which are present, the less likely the patient is to benefit from CPR.

  •  Advanced malignancy
  • Irreversible organ dysfunction
  • Cardiac e.g. heart failure (on echo)
  • Respiratory e.g. COPD- particularly on home oxygen, severe pulmonary hypertension on echo
  • Liver e.g. cirrhosis
  • Renal e.g. CKD, on dialysis
  • Neurological e.g. dementia (not delirium)
  • Extreme old age
  • Frailty syndrome including cachexia
  • Poor function including exercise tolerance:
  • Inability to carry out activities of daily living (washing, dressing etc): need for carers, NH resident
  • Inability to climb 1 flight stairs or walk several metres; bedbound & hoisted, wheelchair bound, zimmer frame
  • The majority of patients, who are not for intubation or level 3 care, should also not be for CPR (although this should be judged on a case-by-case basis).
  • Those with limited function prior to CPR or ICU admission are likely to have even poorer function in the unlikely event of surviving either.

In summary there is a duty to consult over DNACPR decisions but CPR should not be offered if it is deemed futile. Where there is disagreement, a second opinion should be sought. Making anticipatory decisions about CPR is an integral part of good clinical practice. Clinicians avoiding consideration of CPR is potentially negligent. Earlier discussion of treatments including CPR via TEPs and UFTOs is becoming more widespread.

References

1 Fritz Z, Cork N, Dodd A et al. DNACPR decisions: challenging and changing practice in the wake of the Tracey judgement. Clinical Medicine 2014 Vol 14, No 6: 571-6

2 Nolan JP, Soar J, Smith GB et al. Incidence and outcome of in- hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation 2014;85:987–92.

3 Eccles L. Hospital was wrong to place ‘do-not-resuscitate’ order on terminally ill 63-year-old as court rules doctors have duty to consult with patients first. Available online at www.dailymail.co.uk/health/ article-2660098/Hospital-wrong-place-not-resuscitate-notice- terminally-ill-63-year-old-court-rules-doctors-duty-consult-patients- first.html [Accessed 2 October 2014].

4  British Medical Association, Resuscitation Council (UK) and Royal College of Nursing. Decisions relating to Cardiopulmonary Resuscitation. Available online at www.resus.org.uk/pages/ DecisionsRelatingToCPR.pdf [Accessed 21 October 2014].

5  National Confidential Enquiry into Patient Outcome and Death. Time to Intervene? A review of patients who underwent cardiopulmonary resus- citation as a result of an in-hospital cardiopulmonary arrest. London: NCEPOD, 2012. Available online at www.ncepod.org.uk/2012report1/ downloads/CAP_fullreport.pdf [Accessed 2 October 2014].

6 Fritz Z, Malyon A, Frankau JM et al. The Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a mixed methods evaluation of the effects on clinical practice and patient care. PLoS One 2013;8:e70977.

Arup Chakraborty is an consultant in Intensive Care Medicine and Acute Medicine in Milton Keynes Hospital
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