A national form and process
Considering, communicating and recording decisions about whether or not to attempt cardiopulmonary resuscitation (CPR) is a challenging process and can result in misunderstandings, sub-optimal decision-making and communication failures. Such problems have been highlighted by qualitative and quantitative research, the National Confidential Enquiry into Patient Outcomes and Death: ‘Time to Intervene’, a recent review funded by the National Institute for Health Research and the Confidential Inquiry into the Premature Deaths of People with Learning Disability (CiPOLD).
- a reluctance or fear in both patients and doctors to discuss CPR, leading to failures to involve patients in decision-making
- poor communication with patients, and those important to them
- CPR decisions being made in an ad hoc manner, with variation across different care settings, within similar care settings (e.g. hospitals, care homes, GP practices) and among individual clinicians
- unjustified DNACPR decisions being made in people in the context of physical and mental disabilities
- variation in the method of recording CPR decisions, and inconsistency in which methods of recording are accepted in different geographic regions and by different organisations within those regions, making good communication problematic
- people being subjected to CPR attempts that will be of no benefit or are contrary to their wishes, in a range of settings, including their own homes, care homes and hospitals
- although ‘DNACPR’ is meant to apply only to attempts to restart the heart and lungs in the event of a cardiorespiratory arrest, it is often misinterpreted or misapplied in a way that limits other elements of care and treatment
- evidence that those with DNACPR decisions receive poorer care than those with similar conditions and backgrounds without such decisions in place.
Alternative approaches have been developed, and there is evidence that an approach which considers the resuscitation decision amongst overall treatment goals and other treatment choices, and is considered in many more people, will address some of these problems.
The Health Select Committee has recently published an enquiry into end-of-life care. Its report states: “We recommend that the Government review the use of DNACPR orders in acute care settings, including whether resuscitation decisions should be considered in the context of overall treatment plans. This Committee believes there is a case for standardising the recording mechanisms for the NHS in England.”
A Working Group has been established, co-chaired by David Pitcher from the Resuscitation Council (UK), and JP Nolan from the Royal College of Nursing to work collaboratively and build on major work already undertaken in order to develop a national form to record anticipatory decisions about CPR and other life-sustaining treatment. This group will:
- review examples of evidence-based best practice (national and international)
- recruit and involve patient and carer groups
- gain consensus amongst groups of healthcare professionals.
Its aim is to establish an approach which:
- is developed with and is acceptable to patients, those important to them, healthcare professionals, carers and other members of the public
- includes a decision-support framework which supports patients and clinicians in having informed discussions about the benefits and burdens of emergency treatments, including CPR ensures that dialogue between the individual and clinicians is central to decision-making
- can be used across all care settings
- can be used for individuals of all ages is based on evidence and experience from other successful initiatives
- considers a decision about CPR within overall goals of care, focusing on choices of treatments to be given rather than specifically on withholding CPR.
Work is progressing well and further updates will be provided in September.
The Working Group met for the third time in September to continue its work to develop a national form to record anticipatory decisions about CPR and other life-sustaining treatment. In between meetings of the main Working Group, two sub-groups have been working on:
- a prototype form and supporting materials
- a programme for consultation, evaluation and implementation
Significant progress in relation to the aims outlined above
has been made.
The Working Group now consists of a broad range of stakeholders including patients, clinical representatives from across the UK, the intercollegiate community, regulators and academia – see the full list of the group’s membership and terms of reference.
The Working Group will meet next in November and aims to communicate after that meeting a timeline for the implementation of a new national form and supporting guidance. The timeline will extend into mid-2016 and will describe key milestones including public consultation and implementation phases. The public consultation period will open in January 2016 and will be advertised widely. The RC (UK) is funding a project manager to oversee the work to ensure that a new form is made available for use as early in 2016 as is possible.
A further update will follow soon, to include details of the public consultation process.