QUICK REFERENCE GUIDE - Web viewClear and full documentation of decisions about CPR, the reasons for them, and the discussions that informed those decisions, is an essential part of

DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION (DNACPR) POLICY

Version 15

Name of responsible (ratifying) committee Portsmouth Hospitals NHS Trust Resuscitation Committee

Date ratified 22 December 2017

Document Manager (job title) Resuscitation Manager

Date issued 22 January 2018

Review date 22 December 2020

Electronic location Clinical Policies

Related Procedural Documents

Portsmouth NHS Trust Cardiopulmonary Resuscitation Policy;

NHS South of England (Central) Unified DNACPR Adult Policy

Key Words (to aid with searching) DNACPR; Cardiopulmonary Resuscitation; Decision; CPR

Version TrackingVersion Date Ratified Brief Summary of Changes Author

15 22.12.2017 References updatedPolicy aligned to Decisions relating to cardiopulmonary resuscitation: guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing June 2016

N Sayer

14 17.07.2014 Typo’s corrected. Section’s added to Section 6.5 Discharge to differentiate between home and other healthcare settings

N Sayer

13 24.04.2014 Updated to align to the NHS South of England (Central) Unified DNACPR Policy Version 2 dated August 2012

N Sayer

12 23.01.2012 - N Sayer

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) PolicyVersion: 15Issue Date: 22 January 2018Review Date: 22 December 2020 Page 1 of 30

CONTENTS

QUICK REFERENCE GUIDE................................................................................................................7

1. INTRODUCTION..........................................................................................................................11

2. PURPOSE....................................................................................................................................11

3. SCOPE.........................................................................................................................................11

4. DEFINITIONS...............................................................................................................................12

5. DUTIES AND RESPONSIBILITIES..............................................................................................12

6. PROCESS....................................................................................................................................14

6.1 Cardiac or respiratory arrest is unlikely......................................................................................156.2 Unexpected cardiac or respiratory arrest...................................................................................156.3 CPR will not be successful and the patient has capacity...........................................................156.4 CPR will not be successful and the patient lacks capacity.........................................................166.5 Decisions about CPR that are based on a balance of benefit and burdens...............................166.6 There is an Advanced Decision to Refused Treatment (ADRT) and the patient lacks capacity 176.7 Communication..........................................................................................................................176.8 Documenting a DNACPR Decision............................................................................................186.9 Discharges from PHT with a DNACPR Decision in situ.............................................................196.10 Reviewing the Decisions..........................................................................................................196.11 Cancellation of a DNACPR Decision........................................................................................206.12 Suspension of a DNACPR Decision.........................................................................................206.14 Children....................................................................................................................................21

7. TRAINING REQUIREMENTS.......................................................................................................21

8. REFERENCES AND ASSOCIATED DOCUMENTATION...........................................................21

9. EQUALITY IMPACT STATEMENT...............................................................................................22

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS..........................................23

EQUALITY IMPACT SCREENING TOOL...........................................................................................24

APPENDIX 1: ADULT DNACPR RECORD FORM..............................................................................26

APPENDIX 2: NHS SOUTH OF ENGLAND (CENTRAL) PATIENT INFORMATION LEAFLET.........29

APPENDIX 3: DECISION-MAKING AND LEGAL REPRESENTATIVES............................................30

APPENDIX 4: UNIFIED DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION (UDNACPR) POLICY AUDIT TOOL.........................................................................................................................31

APPENDIX 5: USEFUL INFORMATION FOR CLINICIANS...............................................................32


QUICK REFERENCE GUIDE

This policy is an adapted version of the NHS South of England (Central) Unified DNACPR Adult Policy for use in Portsmouth Hospitals NHS Trust (PHT).

This policy must be followed in full when making and implementing Do Not Attempt Cardiopulmonary Resuscitation decisions.

For quick reference the guide below is a summary of actions required. This does not negate the need for all clinical staff involved in the Do Not Attempt Cardiopulmonary Resuscitation decision making process to be aware of and follow the detail of this policy.

1. All clinical staff involved in Do Not Attempt Cardiopulmonary Resuscitation decisions must follow this policy, Decisions relating to cardiopulmonary resuscitation: guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing June 2016 document and the Mental Capacity Act 2005.

2. Decisions about Cardiopulmonary Resuscitation (CPR) will be made on the basis of an individual patient assessment by a doctor ST3 grade and above.

3. Anticipatory decisions about, whether or not to attempt CPR is an important part of good-quality care for any person who is approaching the end of life and/or is at risk of cardiorespiratory arrest. They should be, where possible, be made by the doctors responsible for the patients care during normal working hours.

4. If cardiorespiratory arrest is not expected or foreseeable in the current circumstances or treatment episode, it is not necessary to initiate discussion about CPR with patients.

5. For many people, anticipatory decisions about CPR are best made in the wider context of advance care planning, before a crisis necessitates a hurried decision in an emergency setting.

6. Each decision about CPR should be subject to review based on the person’s individual circumstances. In the setting of an acute illness, review should be sufficiently frequent to allow a change of decision (in either direction) in response to the person’s clinical progress or lack thereof. In the setting of end-of-life care for a progressive, irreversible condition there may be little or no need for review of the decision.

7. For a person in whom CPR may be successful, when a decision about future CPR is being considered there must be a presumption in favour of involvement of the person in the decision-making process. If she or he lacks capacity those close to them must be involved in discussions to explore the person’s wishes, feelings, beliefs and values in order to reach a ‘best interests’ decision. It is important to ensure that they understand that (in the absence of an applicable power of attorney or court-appointed deputy or guardian) they are not the final decision-makers, but they have an important role in helping the healthcare team to make a decision that is in the patient’s best interests.

8. If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable advance decision to refuse treatment (ADRT), specifically refusing CPR, this must be respected.

9. If the healthcare team is as certain as it can be that a person is dying as an inevitable result of underlying disease or a catastrophic health event, and CPR would not re-start the heart and breathing for a sustained period, CPR should not be attempted and a DNACPR decision should be made.

10. Even when CPR has no realistic prospect of success, there must be a presumption in favour of explaining the need and basis for a DNACPR decision to a patient, or to those close to a patient who lacks capacity. It is not necessary to obtain the consent of a patient or of those close to a


patient to a decision not to attempt CPR that has no realistic prospect of success. The patient and those close to the patient do not have a right to demand treatment that is clinically inappropriate and healthcare professionals have no obligation to offer or deliver such treatment.

11. Where there is a clear clinical need for a DNACPR decision in a dying patient for whom CPR offers no realistic prospect of success, that decision should be made and explained to the patient and those close to the patient at the earliest practicable and appropriate opportunity.

12. Where a patient or those close to a patient disagree with a DNACPR decision a second opinion should be offered, although this is not a legal requirement. Endorsement of a DNACPR decision by all members of a multidisciplinary team may avoid the need to offer a further opinion. Discussion with the Clinical Ethics Committee, if available, could be considered.

13. Effective communication is essential to ensure that decisions about CPR are made well and understood clearly by all those involved. There should be clear, accurate, honest and timely communication with the patient and (unless the patient has requested confidentiality) those close to the patient, including provision of information and checking their understanding of what has been explained to them. Agreeing broader goals of care with patients and those close to patients is an essential prerequisite to enabling each of them to understand decisions about CPR in context.

14. Any decision about CPR should be communicated clearly to all those involved in the patient’s care.

15. It is essential that healthcare professionals, patients and those close to patients understand that a decision not to attempt CPR applies only to CPR and not to any other element of care or treatment. A DNACPR decision must not be allowed to compromise high quality delivery of any other aspect of care.

16. A DNACPR decision does not override clinical judgement in the unlikely event of a reversible cause of the person’s respiratory or cardiac arrest that does not match the circumstances envisaged when that decision was made and recorded. Examples of such reversible causes include but are not restricted to – choking, a displaced tracheal tube or a blocked tracheostomy tube.

17. Clear and full documentation of decisions about CPR, the reasons for them, and the discussions that informed those decisions, is an essential part of high-quality care. This often requires documentation in the health record of detail beyond the content of the DNACPR form. Where such discussions are not practicable or not appropriate, the reasons for this must be documented fully.

18. The DNACPR decision form in itself is not legally binding. The form should be regarded as an advance clinical assessment and decision, recorded to guide immediate clinical decision-making in the event of a patient’s cardiorespiratory arrest or death. The final decision regarding whether or not attempting CPR is clinically appropriate and lawful rests with the healthcare professionals responsible for the patient’s immediate care at that time.

19. A valid DNACPR form should accompany a patient when they move from one setting to another; including discharge from PHT. Prior to discharge all DNACPR decisions should be reviewed and if a DNACPR decision continues to apply when a patient is discharged from PHT Sections 4 and 5 should be completed. Once completed the lilac copy should be given to the patient or ambulance crew as appropriate following discussion with the patient and/or carers.

20. Where no explicit decision about CPR has been considered and recorded in advance there should be an initial presumption in favour of CPR. However, in some circumstances where there is no recorded explicit decision (for example for a person in the advanced stages of a terminal illness where death is imminent and unavoidable and CPR would not be successful) a carefully


considered decision not to start inappropriate CPR can be made by a doctor ST3 and above.

21. All DNACPR decisions in Portsmouth Hospitals NHS Trust must be recorded on the DNACPR documentation form. See Appendix 1.

22. If the DNACPR decision is cancelled, the doctor should place two diagonal lines in black ballpoint ink on all pages of the form and the word “CANCELLED” written clearly between them. The doctor must print their name, sign and date and time this change. The rationale for cancelling the DNACPR decision must be recorded in the patient’s medical notes. The cancelled form must be filed at the back of the patient’s medical notes.


1. INTRODUCTION

This policy is an adapted version of the NHS South of England (Central) Unified DNACPR Adult Policy for use in Portsmouth Hospitals NHS Trust (the Trust or PHT).

All patients are presumed to be “For CPR” unless:o A valid DNACPR decision has been made and documented on the standardised Unified

Do Not Attempt Cardiopulmonary Resuscitation (uDNACPR) form for adult DNACPR decisions (see Appendix 1) or

o An Advance Decision to Refuse Treatment (ADRT) prohibits CPR

Survival following Cardiopulmonary Resuscitation (CPR) in adults is between 5-20% depending on the circumstances. Although CPR can be attempted on any person prior to death, there comes a time for some people when it is not in their best interests to do so. It may then be appropriate to consider making a Do Not Attempt CPR (DNACPR) decision to enable the person to die with dignity.

All DNACPR decisions are based on current legislation and guidance to ensure that when CPR would not restart the heart and breathing of the individual, it will not be attempted.

For situations when CPR might restart the heart and breathing of the individual, discussion will take place with that individual if this is possible (or with other appropriate individuals for people without capacity), although people have a right to refuse to have these discussions.

The following sections of the Human Rights Act (1998) are relevant to this policy: the individual’s right to life (article 2) to be free from inhuman or degrading treatment (article 3) respect for privacy and family life (article 8) freedom of expression, which includes the right to hold opinions and receive information

(article 10) to be free from discriminatory practices in respect to those rights (article 14).

2. PURPOSE

This policy will provide clear guidance for clinical staff and a framework to ensure that DNACPR decisions:

refer only to CPR and not to any other aspect of the individual’s care or treatment options respect the wishes of the individual, where possible reflect the best interests of the individual provide benefits that are not outweighed by burden

3. SCOPE

This policy applies to all staff (including voluntary workers, students, locums and agency) within PHT, the MDHU (Portsmouth) and Carillion, whilst acknowledging that, for staff other than those of the Trust, the appropriate line management or chain of command will be followed in all cases.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

This policy applies to DNACPR decisions for patients who are 18 years and over.


4. DEFINITIONS

Advance Decision to Refuse Treatment (ADRT): a decision by an individual to refuse a particular treatment in certain circumstances. A valid ADRT is legally binding for healthcare staff.

Cardiopulmonary Resuscitation (CPR). Interventions delivered with the intention of restarting the heart and breathing. These will include chest compressions and ventilations and may include attempted defibrillation and the administration of drugs.

Court-appointed deputy is appointed by the Court of Protection (Specialist Court for issues relating to people who lack capacity to make specific decisions) to make decisions in the best interests of those who lack capacity.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) refers to not making efforts to restart breathing and / or the heart in cases of respiratory / cardiac arrest. It does not refer to any other interventions / treatment / care such as fluid replacement, feeding, antibiotics etc.

Cardiac Arrest (CA) is the sudden cessation of mechanical cardiac activity, confirmed by the absence of a detectable pulse, unresponsiveness, and apnoea or agonal gasping respiration. In simple terms, cardiac arrest is the point of death.

Independent Mental Capacity Advocate (IMCA). An IMCA supports and represents a person who lacks capacity to make a specific decision at a specific time and who has no family or friends who are appropriate to represent them.

Lasting Power of Attorney (LPA) / Personal Welfare Attorney (PWA). The Mental Capacity Act (2005) allows people over the age of 18 years of age, who have capacity, to make a Lasting Power of Attorney by appointing a Personal Welfare Attorney who can make decisions regarding health and well-being on their behalf once capacity is lost.

Mental Capacity: An individual over the age of 16 is presumed to have mental capacity to make decisions for themselves unless there is evidence to the contrary. Individuals that lack capacity will not be able to:

understand information relevant to the decision retain that information use or weigh that information as part of the process of making the decision communicate the decision, whether by talking or sign language or by any other means.

Mental Capacity Act (2005) (MCA), was fully implemented on 1 October 2007. The aim of the Act is to provide a much clearer legal framework for people who lack capacity and those caring for them by setting out key principles, procedures and safeguards. Under the Mental Capacity Act (2005), clinicians are expected to understand how the Act works in practice and the implications for each patient for whom a DNACPR decision has been made. Useful information on applying the MCA into clinical practice can be found in Appendix 5.

NHS England South (Central). South Central Strategic Health Authority (SHA) and the South West and South East SHA’s merged in 2012 to form NHS England South. This unified DNACPR policy was developed by South Central SHA so only applies in NHS England South central region

5. DUTIES AND RESPONSIBILITIES

The Resuscitation ManagerThe Resuscitation Manager is responsible for ensuring that:


DNACPR awareness and principles are included in all classroom resuscitation training programmes delivered to PHT;

The Resuscitation Link Network is utilised to cascade information to the clinical departments; All data collected from the returned part of the Do Not Attempt Cardiopulmonary

Resuscitation record forms is entered onto the database, to support audit of compliance; Quarterly reports are produced for the Resuscitation Committee using the data from the

Resuscitation Database to present to the PHT Resuscitation Committee to monitor compliance to this policy;

Audits requested by the NHS England South are completed as required.

The Resuscitation Link Network membersThe Network, which meets quarterly, consists of resuscitation link champions from each clinical area and the Resuscitation Officers, each of whom chair the Network on a rolling basis. The Network is utilised to cascade information to and from the clinical areas, to support organisational learning and feedback

Line ManagersLine Managers are responsible for:

Releasing their staff to attend Resuscitation Training, in accordance with the requirements identified in the training needs analysis

Answering queries about this policy as it is relevant to their areas Taking any queries that they cannot answer to the link champions or the Resuscitation

Manager who will take it to the appropriate forum for resolution.

All Clinical StaffAll clinical staff are responsible for ensuring that they:

Cooperate with the implementation of this policy; Read, comply and maintain up-to-date awareness of the DNACPR policy; Attend training as required, to familiarise themselves and enable compliance with, the

DNACPR policy relevant to their role and responsibilities; and Raise any queries about implementation of this policy with their line manager, Resuscitation

Officers or the Resuscitation Manager.

PHT Resuscitation Committee The Resuscitation Committee is responsible for ensuring that:

This procedural document is up to date, technically accurate, is in line with evidence-based best practice and has been produced following consultation with stakeholders

Processes to enable audits of compliance with the practices as detailed in this policy are in place and that the actions identified as a result of those audits are implemented

Through the Chair, assurance on the effectiveness of this policy and the Trust’s procedures for managing decisions relating to DNACPR, is provided through an quarterly reports to the committee, including any necessary recommendations to address identified deficits;

The quarterly reports from the Resuscitation Manager are reviewed and standards are monitored.

Clinical Service Centre Governance MeetingsThese groups are responsible for receiving monthly information on attendance at resuscitation training and for addressing any lack of compliance with the required attendance, to ensure all relevant staff are appropriately trained in this essential skill.


6. PROCESS

Decision-making framework

No

Yes

No

Yes

Yes

No

YesNo

No

Yes

• If cardiorespiratory arrest occurs in the absence of a recorded decision there should be an initial presumption in favour of attempting CPR.

• Anticipatory decisions about CPR are an important part of high- quality health care for people at risk of death or cardiorespiratory arrest.

• Decisions about CPR are sensitive and complex and should be undertaken by experienced members of the healthcare team with appropriate competence.

• Decisions about CPR require sensitive and effective communication with patients and those close to patients.

• Decisions about CPR must be documented fully and carefully.• Decisions should be reviewed with appropriate frequency

and when circumstances change.• Advice should be sought if there is uncertainty.

The patient must be involved in deciding whether or not CPR will be attempted in the event of cardiorespiratory arrest.

Respect and document their refusal (see section 6.3). Discussion with those close to the patient may be used to guide a decision in the patient’s best interests, unless confidentiality restrictions prevent this.

Is the patient willing to discuss his/her wishes regarding CPR?

Does the patient lack capacity?

Discussion with those close to the patient must be used to guide a decision in the patient’s best interests (see section 10). When the patient is a child or young person, those with parental responsibility should be involved in the decision where appropriate, unless the child objects (see section 11).

Does the patient lack capacity AND have an advance decisionspecifically refusing CPR

OR have an appointed attorney, deputy or guardian?

If a patient has made an advance decision refusing CPR, and the criteria for applicability and validity are met, this must be respected.If an attorney, deputy or guardian has been appointed they must be consulted (see sections 9.1 and 10).

Is there a realistic chance that CPR could be successful?

Is cardiac or respiratory arrest a clear possibility for the patient?

If a DNACPR decision is made on clear clinical grounds that CPR would not be successful there should be a presumption in favour of informing the patient of the decision and explaining the reason for it (see section 5). Those close to the patient should also be informed and offered explanation, unless a patient’s wish for confidentiality prevents this.Where a patient lacks capacity and has a welfare attorney or court- appointed deputy or guardian, this representative should be informed of the decision not to attempt CPR and the reasons for it, as part of the ongoing discussion about the patient’s care.Where a patient lacks capacity, the decision should be explained to those close to the patient without delay. If this is not done immediately, the reasons why it was not practicable or appropriate must be documented (see section 5).If the decision is not accepted by the patient, their representative or those close to them, a second opinion should be offered.

It is not necessary to discuss CPR with the patient unless they express a wish to discuss it.


Taken from Decisions relating to cardiopulmonary resuscitation: guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing June 2016 Pg 6 Decisions relating to Cardiopulmonary Resuscitation6.1 Cardiac or respiratory arrest is unlikelyFor the majority of people receiving care in a hospital, the likelihood of cardiopulmonary arrest is small; therefore no discussion of such an event routinely occurs unless raised by the individual. There is no ethical or legal requirement to initiate discussion about CPR with patients, or with those close to patients who lack capacity, if the risk of cardiorespiratory arrest is considered low.

6.2 Unexpected cardiac or respiratory arrest6.2.1 In the event of an unexpected cardiac arrest CPR will take place in accordance with the current Cardiopulmonary Resuscitation policy.

6.2.2 There may be some situations in which CPR is commenced on this basis, but during the resuscitation attempt further information comes to light that makes continued CPR inappropriate. That information may consist of a DNACPR decision, or a valid and applicable advance decision refusing CPR in the current circumstances, or may consist of clinical information indicating that CPR will not be successful. In such circumstances, continued attempted cardiopulmonary resuscitation would be inappropriate.

6.3 CPR will not be successful and the patient has capacity6.3.1 Decisions about CPR may be made following consideration of a balance of benefits and burdens (see section 6.5). In most other cases, the decision not to attempt CPR is a clinical decision. If the clinical team has good reason to believe that a person is dying as an inevitable result of advanced, irreversible disease or a catastrophic event and that CPR will not re-start the heart and breathing for a sustained period CPR should not be offered or attempted.

6.3.2 The person’s individual circumstances and the most up-to-date evidence and professional guidance must be considered carefully before any CPR decision is made. The ultimate responsibility for the decision rests with the most senior clinician (ST3 and above) responsible for the person’s care, but there should be:

• discussion of the decision whenever possible with the other members of the healthcare team to ensure their agreement or consensus;• a presumption in favour of explaining the need for and reasons for the decision to the patient or to those representing a patient without capacity.

6.3.3 Where people are known to have an advanced chronic illness, discussion and explanation about the realities of attempting CPR should be considered and, where appropriate, offered in advance of the last few weeks or days of life.

6.3.4 If a DNACPR decision is made on clear clinical grounds that CPR would not be successful the courts have stated there should be a presumption in favour of informing the patient of the decision and explaining the reason for it. Those close to the patient should also be informed and offered explanation, unless a patient’s wish for confidentiality prevents this. There needs to be convincing reasons not to involve the patient.

6.3.5 Some people make it clear that they do not wish to talk about dying or to discuss their end-of-life care, including decisions relating to CPR. When such wishes are expressed they should be respected.

6.3.6 There will be circumstances when giving information and explanations about CPR decisions at an early stage to a person who is seriously ill may cause harm. However, failure to make a timely DNACPR decision when CPR will not be successful will result in people receiving inappropriate CPR that they would not have wanted. Faced with such a situation, clinicians should make the DNACPR decision that is needed and record fully their reasons for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) PolicyVersion: 15Issue Date: 22 January 2018Review Date: 22 December 2020 Page 10 of 30

https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/

not explaining it to the patient at that time, but also ensure that there is active, repeated review of the decision and of the patient’s ability to accept explanation of it without harm, so that the patient is informed at the earliest possible opportunity.

6.3.8 In any situation, a clinician who makes a conscientious decision not to inform a patient of a DNACPR decision, as they believe that informing the patient is likely to cause them harm, should document clearly their reasons for reaching this decision.

6.3.9 The DNACPR form (Appendix 1) Section 1A) should be completed for a DNACPR decision where CPR will not be successful and the patient has capacity, including a record of the discussions with the person and whether the family or carers have been informed.

6.4 CPR will not be successful and the patient lacks capacity6.4.1 If a person lacks capacity and has appointed a welfare attorney whose authority extends to making decisions of this nature on their behalf, or if a court has appointed a deputy or guardian with similar authority to act on the individual’s behalf, this attorney, deputy or guardian must be informed of the decision and the reason for it.

6.4.2 If the welfare attorney, deputy or guardian does not accept the decision, a second opinion should be offered, whenever possible, although this is not a legal requirement. Discussion with the Clinical Ethics Committee, if available, could be considered.

6.4.3 When a person lacks capacity and a decision is made that CPR will not be attempted because it will not be successful, those close to that person must be informed of this decision and of the reasons for it, unless this is contraryto confidentiality restrictions expressed by the patient when they had capacity.Sensitive and careful explanation is needed to help people to understand that the intention is to spare the patient traumatic and undignified treatment that will be of no benefit, as they are dying, not to withhold life-saving treatment, and not to withhold any other care or treatment that they need.

6.4.4 When a DNACPR decision is needed in the setting of an acute, severe illness with no realistic prospect of recovery it is important that the decision is not delayed if the patient’s next of kin/carer’s are not contactable immediately to have the decision explained to them i.e. out of hours. An ST3 or above must make a timely decision in the patient’s best interests in order to provide them with high-quality care, and that decision and the reasons for making it at that point must be documented fully.

In this situation clinicians should:• record fully their reasons for not explaining a DNACPR decision to those close to the patient at that time, documenting clearly why to do so would not be practicable or appropriate.• ensure that a plan for on-going active review of the decision is recorded and implemented.• ensure that a plan for informing those close to the patient of the decision at the earliest practicable and appropriate opportunity is recorded and implemented.• be conscious that simply because it may be inconvenient or undesirable to inform those close to the patient of a decision at a particular time does not, in itself, meet the threshold for it being not practicable and appropriate.

6.4.5 The DNACPR form (Appendix 1) Section 1A) should be completed for a DNACPR decision where CPR will not be successful and the patient lacks capacity, including recording a reason why the person has not been informed and which relevant other has been informed, and if not why not.


6.5 Decisions about CPR that are based on a balance of benefit and burdens

6.5.1 If CPR may be successful in re-starting a person’s heart and breathing for a sustained period, the potential benefits of prolonging life must be balanced against the potential harms and burdens of CPR. This is not solely a clinical decision. For a patient with capacity there should be open dialogue and shared decision-making between the patient and professionals, unless the patient declines any such discussion. For a patient who lacks capacity the requirements for an assessment and decision based on their best interests must be followed.

6.5.2 People should be informed sensitively about what CPR involves and its possible risks and adverse effects, as well as its likely chance of success in their specific circumstance, to try to help them to make informed decisions about whether or not they would want it.

6.5.3 Careful explanation will be needed to help them to understand that: cardiorespiratory arrest is part of the final stage of dying CPR is unlikely to be successful when someone is dying from an advanced and

irreversible or incurable illness healthcare professionals may start CPR inappropriately when someone dies

unless a DNACPR decision has been made and recorded

6.3.7 The DNACPR form (Appendix 1) Section 1B) should be completed for a DNACPR decision where CPR maybe successful, but followed by a length and quality of life which would not be of overall benefit to the person. This includes a record of the discussions with the person or relevant others.

6.6 There is an Advanced Decision to Refused Treatment (ADRT) and the patient lacks capacity6.6.1 CPR must not be attempted if it is contrary to a valid and applicable ADRT (in England and Wales) made when the person had capacity.

6.6.2 In England and Wales advance decisions are covered by the Mental Capacity Act 2005. The Act confirms that an ADRT refusing CPR will be valid, and therefore legally binding on the healthcare team, if:

• the person was 18 years old or over and had capacity when the decision was made• the decision is in writing, signed and witnessed• it includes a statement that the advance decision is to apply even if the person’s life is at risk• the advance decision has not been withdrawn• the person has not, since the advance decision was made, appointed a welfare attorney to make decisions about CPR on their behalf• the person has not done anything clearly inconsistent with its terms• the circumstances that have arisen match those envisaged in the advance decision.

6.6.3 If an ADRT does not meet these criteria but appears to set out a clear indication of the person’s wishes, it will not be legally binding but should be taken into consideration in determining the person’s best interests.

6.7 Communication6.7.1 If a DNACPR decision is deemed appropriate there is a presumption that a discussion will be held between the clinician (ST3 and above) and the individual and the following points need to be considered:

The DNACPR decision and discussion with the individual must be recorded on the DNACPR form and documented in the medical notes. Those close to the patient should also be informed and offered explanation, unless a patient’s wish for confidentiality prevents this.


If the individual is unwilling to discuss their wishes this should be respected and the ST3 or above should document their refusal. Discussion with those close to the patient may be used to guide a decision in the patient’s best interests, unless confidentiality restrictions prevent this.

Where a patient lacks capacity, the decision should be explained to those close to the patient without delay. If this is not done immediately, the reasons why it was not practicable or appropriate must be documented

Any discussions with those close to the patient must be used to guide a decision in the patient’s best interests.

6.7.2 Confidentiality: If the individual has capacity to make decisions about how their clinical information is shared, their agreement must always be sought before sharing this with family and friends. Refusal by an individual with capacity to allow information to be disclosed to family or friends must be respected. Where individuals lack capacity, and their views on involving family and friends are not known health and social care staff may disclose confidential information to people close to them where this is necessary to discuss the individual’s care and is not contrary to their interests.

6.7.3 Communicating DNACPR decisions can be particularly challenging for healthcare professionals. However, failure to explain clearly to patients or those close to them why decisions about CPR are needed, that a DNACPR decision has been made, and the basis for it, can lead to misunderstanding, potentially avoidable distress and dissatisfaction, and in some instances complaint or litigation. As with any other aspect of care, healthcare professionals must be able to justify their decisions.

6.7.4 The DNACPR information leaflet (see Appendix 2) should be made available, where appropriate, to individuals and their relatives or carers.

6.8 Documenting a DNACPR Decision6.8.1 Once the decision has been made, it must be recorded on the approved Adult DNACPR form (see Appendix 1) and this becomes the first page of the medical notes.

6.8.2 The original (outer) copy of the PHT DNACPR Record Form must remain as the first page of the patient’s medical records whilst valid. Once cancelled it must be filed at the back of the medical notes.

6.8.3 The lilac layer is used when a patient is discharged from PHT with a DNACPR decision in situ, see section 6.5 for more information. The lilac copy should be given to the patient or ambulance crew as appropriate. This copy of the DNACPR decision must be available to travel with the patient for communication purposes and will ensure that the ambulance staff are aware of the patient’s CPR status during the transfer, and it provides them with the necessary documentation to comply with their protocols. This copy should then be left with the patient or their carers. It is therefore essential that the DNACPR decision has been discussed prior to discharge with the patient and/or carers where applicable.

6.8.4 The blue layer watermarked ‘Audit Copy. Return to Resus Dept’ should be returned to the Resuscitation Department for audit purposes ASAP when either the patient has been discharged or has died.

6.8.5 If, on admission, a patient has the lilac part of an uDNACPR form from the community setting or a valid Advance Decision that specifies CPR should not be attempted a medical review must take place as part of the admission process. If the patient is to remain DNACPR then this decision should be recorded on the PHT version of the form. The original community documents should be stapled inside the PHT version of the form for safe keeping and on discharge from PHT these documents should go with the patient.


6.8.6 As well as completing the approved DNACPR form, information regarding the background to the decision, the reasons for the decision, those involved in the decision and a full explanation of the process must be recorded in the individual’s notes / care records / care plans.

6.8.7 Whilst the patient is an in-patient in Portsmouth Hospitals NHS Trust a valid DNACPR form will be the first page of the medical notes.

6.8.8 In PHT a doctor grade ST3 and above can make a DNACPR decision. This should be, where possible, done by the doctors responsible for the patients care during normal working hours. The decision should be verified by a consultant within 48 hours. If more than 48 hours has elapsed the decision is still valid and the consultant’s verification must be sought as a matter of urgency. If the person making the decision is the consultant then verification is not required.

6.9 Discharges from PHT with a DNACPR Decision in situ

To the patient’s home6.9.1 Prior to discharge all DNACPR decisions must be reviewed as part of the discharge planning process. If a DNACPR decision is to remain in situ/valid on discharge from PHT then the doctor, grade ST3 or above, must discuss this decision and the implications, with the patient or if they lack capacity the carer. If the person is competent and it is considered that informing them of the decision would not be likely to cause distress then this should be sensitively done.The same approach should be taken towards discussion with family members and carers.

If such discussion is likely to cause undue distress then it is usually impossible to place a DNACPR form in the person’s home until further discussions have taken place.

6.9.2 Following this discussion the lilac layer should be given to the patient/carer to take with them into the community setting. This will also need to be included in the discharge letter and summary so the GP is aware. The situation where this is most likely to occur is when a patient is discharged for End of Life (EOL) care at home or back to a nursing home. This conversation and subsequent action should be documented in full in the patient’s notes.

6.9.3 If there is no explicit documentation by the doctor that the DNACPR decision is in situ/valid on discharge to the patient’s own home from PHT and they haven't given the lilac layer to the patient nor had any discussions then as per policy the DNACPR becomes invalid on discharge. In this situation, even if there was a DNACPR decision in place during the whole PHT admission, the patient would not take the lilac layer home with them.

Appendix 3, the PHT DNACPR Discharge Flowchart & Checklist should be used for guidance to ensure that all the correct procedures have been followed.

To other healthcare settings (e.g. hospice, care home)

6.9.4 When transferring the person between healthcare settings all staff involved in the transfer of care of a person need to ensure that:

• the receiving institution is informed of the DNACPR decision.• where appropriate, the person (or those close to the person if they lack capacity) has

been informed of the DNACPR decision• the decision is communicated to all members of the health and social care teams involved in the person’s ongoing care.

6.10 Reviewing the Decisions6.10.1 This decision will be regarded as ‘indefinite’ unless:

A definite review date is specifiedDo Not Attempt Cardiopulmonary Resuscitation (DNACPR) PolicyVersion: 15Issue Date: 22 January 2018Review Date: 22 December 2020 Page 14 of 30

There are improvements in the person’s condition Their expressed wishes change where a 1b and 1c decision is concerned

The frequency of review should be determined by the health professional in charge of the individual’s care at the time of the initial decision.6.10.2 It is important to note that the person’s ability to participate in decision-making may fluctuate with changes in their clinical condition. Therefore, when a DNACPR decision is reviewed, the clinician must consider whether the person can contribute to the decision-making process each time. It is not usually necessary to discuss CPR with the person each time the decision is reviewed, if they were involved in the initial decision. Where a person has previously been informed of a decision and it subsequently changes, they should be informed of the change and the reason for it.

6.10.3 Prior to discharge all DNACPR decisions should be reviewed and if the decision is to remain valid on discharge from PHT then Section 6.5 should be followed.

6.11 Cancellation of a DNACPR Decision6.11.1 In rare circumstances, a decision may be made to cancel or revoke the DNPCPR decision by a doctor ST3 grade or above. If the decision is cancelled, the form should be crossed through with two diagonal lines in black ball-point pen and the word ‘CANCELLED’ written clearly between them, dated and signed by the healthcare professional. It is the responsibility of the healthcare professional cancelling the DNACPR decision to communicate to all parties informed of the original decision. The DNACPR form is then filed in the back of the patient’s notes

6.12 Suspension of a DNACPR Decision6.12.1 There are some circumstances where clinical staff may make the decision to commence CPR for a patient who has a valid documented DNACPR decision. Examples of such situations are when there is a readily reversible cause, such as choking or a blocked tracheostomy tube that was not envisaged when the DNACPR decision was made.In such situations CPR would be appropriate, while the reversible cause is treated, unless the patient has specifically refused intervention in these circumstances.

6.12.2 Some procedures could precipitate a cardiac arrest, for example, induction of anaesthesia, cardiac catheterisation, pacemaker insertion or surgical operations etc. Under these circumstances, the DNACPR decision should be reviewed prior to procedure and a decision made as to whether the DNACPR decision should be suspended. Discussion with key people, including the person if appropriate, will need to take place.

6.13 Situations where there is lack of agreement 6.13.1 A person with mental capacity may refuse CPR, even if they have no clinical reason to do so. This should be clearly documented in the medical and nursing notes after a thorough, informed discussion with the individual, and possibly their relatives. In these circumstances they should be encouraged to write an ADRT. An ADRT is a legally binding document which has to be adhered to, it is good practice to have a DNACPR form with the ADRT but it is not essential.

Please note if the person had capacity prior to arrest, a previous clear verbal wish to decline CPR should be carefully considered when making a best interests decision. The verbal refusal should be documented by the person to whom it is directed and any decision to take actions contrary to it must be robust, accounted for and documented. The person should be encouraged to make an ADRT to ensure the verbal refusal is adhered to.

6.13.2 Patients have no legal right to treatment that is clinically inappropriate. Sometimes patients or those close to them will try to demand CPR in a situation where it is clinically inappropriate. If the healthcare team has good reason to believe that CPR will not re-start the heart and breathing, this should be explained in a sensitive but unambiguous way.


6.13.3 These decisions, and the subsequent discussions informing the patient of the healthcare team’s decision, can be difficult. They should be undertaken by clinicians with the relevant training and expertise, both in assessing the likely outcome and appropriateness of CPR, and with the relevant communication skills.

6.13.4 If the patient does not accept the decision a second opinion should be offered, whenever possible. Similarly, if those close to the patient do not accept a DNACPR decision

in these circumstances, despite careful explanation, a second opinion should be offered. The courts have confirmed that there is no legal obligation to offer to arrange a second opinion in cases where the patient is being advised and treated by a multi-disciplinary team all of whom take the view that a DNACPR decision is appropriate. Discussion with the Clinical Ethics Committee, if available, could be considered.

6.14 Children6.14.1 DNACPR decisions involving children are complex and must be undertaken by a Consultant only. Within PHT, these decisions are normally made as part of advance care planning and following in-depth discussion with the family

6.14.2 All discussions and decisions are recorded in the health records and the principles of review, cancellation, communication, on-going patient care, temporary suspension and confidentiality (where appropriate) apply.

6.14.3 A specific document may be used called a Paediatric Advance Care Plan and these are available in the PHT Paediatric Department. Use of this document should involve the relevant Paediatric Consultant.

6.14.4 Under particular circumstances it may be necessary to involve the Courts. If this should prove to be the case, the Trust’s Legal Services Manager must be contacted.

7. TRAINING REQUIREMENTS

7.1 Training forms part of the Trust’s Essential Skills and Training Requirements; as identified in the Training Needs Analyses. It is included in mandatory Corporate Induction and in Essential Updates as part of the Adult Basic Life Support training session which is an annual update for clinical staff.

7.2 All training is recorded on the ESR from which the Learning and Development Team provide a monthly heat map to each CSC, to enable monitoring of compliance

7.3 Compliance is further monitored through the CSC performance reviews with the Executive Team

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Internal Portsmouth NHS Trust Cardiopulmonary Resuscitation policy. Located on PHT intranet in the

Clinical Policies section

External Advance Decisions to Refuse Treatment, a guide for health and social care professionals.

London: Department of Health ADRT guide [Accessed 14-11-2017]


http://www.ncpc.org.uk/publication/advance-decisions-refuse-treatment-guide-health-and-social-care-professionals

http://pht/PoliciesGuidelines/ClinicalPolicies/Lists/Links/All%20Links.aspx

Coroners and Justice Act 2009 London: Crown Copyright. http://www.legislation.gov.uk/ukpga/2009/25/contents [Accessed 14-11-2017]

General Medical Council (2010) Treatment and care towards the end of life: good practice in decision making Guidance for doctors. GMC | Treatment and care towards the end of life: good practice in decision making [Accessed 14-11-2017]

Human Rights Act. (1998) London: Crown Copyright. http://www.opsi.gov.uk/acts/acts1998/ukpga_19980042_en_1 [Accessed 14-11-2017]

Mental Capacity Act. (2005) London: Crown Copyright. http://www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1 [Accessed 14-11-2017]

NHS End of Life Care Programme & the National Council for Palliative Care (2008)

NHS South of England (Central) Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Adult Policy. Version 2. August 2012 End of Life Care | University of Southampton [Accessed 14-11-2017]

Decisions relating to cardiopulmonary resuscitation: guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing June 2016Decisions relating to Cardiopulmonary Resuscitation [Accessed 14-11-2017]

The Mental Capacity Act (Jan 2016) Code of Practice. Further information can be obtained from the Office of the Public Guardian Mental Capacity Act [Accessed 14-11-2017]

9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignityQuality of careWorking togetherEfficiency

This policy should be read and implemented with the Trust Values in mind at all times.


http://www.justice.gov.uk/protecting-the-vulnerable/mental-capacity-act


http://www.southampton.ac.uk/healthsciences/business_partnership/services/eolc.page

http://www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1

http://www.opsi.gov.uk/acts/acts1998/ukpga_19980042_en_1

http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp

http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp

http://www.legislation.gov.uk/ukpga/2009/25/contents


10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum requirement to be

monitored

Lead Tool Frequency of Report of

Compliance

Reporting arrangements Lead(s) for acting on Recommendations

The DNACPR decision making process

Resuscitation Manager

Audit Tool (Appendix 4)Minimum of 50 DNACPR forms

50 sets of notes

Annually Results of the rolling audit will be presented to the Resuscitation Committee quarterly.Information on the status of actions planning and learning, as a result of the audit will be reported quarterly to the Patient Safety Working Group

The Resuscitation Manager and/or Chair of the Resuscitation Committee

This document will be monitored to ensure it is effective and to assure compliance.


EQUALITY IMPACT SCREENING TOOLTo be completed and attached to any procedural document when submitted to the

appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: DNACPR Policy

Date of Assessment 22 December 2017 Responsible Department

Resuscitation

Name of person completing assessment

N Sayer Job Title Resuscitation Manager

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

Age No

Disability No

Gender reassignment No

Pregnancy and Maternity No

Race No

Sex No

Religion or Belief No

Sexual Orientation No

Marriage and Civil Partnership No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents

Stage 2 – Full Impact Assessment


http://www.legislation.gov.uk/ukpga/2010/15/contents

What is the impact Level of Impact

Mitigating Actions(what needs to be done to minimise /

remove the impact)

Responsible Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance CommitteeClinical Service Centre Procedural Document: Clinical Service Centre Governance CommitteeCorporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee


APPENDIX 1: Adult DNACPR Record form




APPENDIX 2: NHS South of England (Central) Patient Information Leaflet

This patient information leaflet can be obtained from the Resuscitation Department Tel: 023 92286110 or Ext: 6110 or downloaded from End of Life Care | University of Southampton




APPENDIX 3: Decision-making and legal representatives

Decisions relating to cardiopulmonary resuscitation: guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing June 2016 Page 23 Decisions relating to Cardiopulmonary Resuscitation



APPENDIX 4: Unified Do Not Attempt Cardiopulmonary Resuscitation (uDNACPR) Policy Audit Tool

100% compliance required for shaded area

DNACPR FormQuestion

Yes

No

Not

R

ecor

ded

Comments (for e.g. no address, illegible, what’s missing? If no, why? etc)

1 Are there clear patient details?2 Is the date of DNACPR decision completed?3 What reason for DNACPR decision has been completed?

1a1b1c

4 Has more than 1 reason been ticked?5 If section 1a has been ticked, is there CLEAR and

APPROPRIATE information regarding why the decision has been made?

6 Has the person been informed of the decision?7 If the person has not been informed has a relevant other?8 Who has made the decision?

GPConsultantAccredited NurseOther

9 Is the record clearly dated, timed and signed correctly?10 Has the decision been verified (Acute Trusts only) if

appropriate?11 Have the following sections been completed?

Section 3 - ReviewSection 4 - Who has been informedSection 5 – Other important information

Person’s Notes Question

Yes

No

Not

re

cord

ed

Comments (If no or not recorded, why?)

1 Was the form initiated in your organisation?2 Is the decision documented in the person’s notes?3 Are the notes clearly dated, timed and signed correctly?

4a Is there evidence of discussion?4b Who was it discussed with?

PersonRelevant other

4c If there is no evidence of discussion, is there evidence of why decision was not discussed with the person?

5 Is there evidence since the DNACPR decision has been made, that CPR has been carried out?

6 Is there evidence of a mental capacity assessment?

APPENDIX 5: Useful Information for Clinicians


Assessing CapacityPatients over 16 years of age are presumed to have capacity to make decisions for themselves, unless there is evidence to the contrary. The Mental Capacity Act (2005) Code of Practice, Chapter 4 details what must be considered when assessing a person’s capacity to make a decision.

There are 2 questions to assessing capacity

1. Does the patient have an impairment of the mind or brain or some disturbance that affects the way the brain or mind works e.g. mental illness dementia, loss of consciousness, alcoholism, drug addiction etc

2. Does the impairment or disturbance mean that the individual is unable to make the specific decision when required to do so

It is important to note that capacity can vary depending on the question being asked and can fluctuate, just because a patient lacks capacity today does not mean they will lack capacity tomorrow.

The points below are used to assess question 2 above.

Individuals are considered legally unable to make decisions for themselves if they are unable to:

Understand the information relevant to the decision Retain that information Use or weigh that information as part of the process of making the decisions, or Communicate the decisions (whether by talking, using sign language, visual aids or

by other means).

The first 3 points above need to be applied together so if a person cannot do any of the first 3 points they will be treated as unable to make a decision. The fourth only applies in circumstances where people cannot communicate their decision in any way.

Advance Decisions to Refuse TreatmentIt is well established in law and ethics that adults with capacity have the right to refuse any medical treatment, even if it results in death.

If the patient is not currently being treated in a healthcare institution then the patient should be advised they can make a formal, written advance decision. Age UK has an information sheet on advance decisions which patients may find useful Age UK Factsheet 72 Advance Decisions and the Office of the Public Guardian also has guidance on this subject.

Advance Decisions refusing CPR are covered by the Mental Capacity Act (2005). They are valid and legally binding on the healthcare team if:

The patient was 18 years old or over and had capacity when the decision was made

The decision is in writing, signed and witnessed

It includes a statement that the advance decision is to apply even if the patient’s life is at risk

The advance decision has not been withdrawn

The patient has not, since the advance decision was made, appointed a welfare attorney to make decisions about CPR on their behalf

The patient has not done anything clearly inconsistent with its terms

The circumstances that have arisen match those envisaged in the advance decision.


http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/FS72_Advance_decisions_advance_statements_and_living_wills_fcs.pdf?dtrk=true

http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/FS72_Advance_decisions_advance_statements_and_living_wills_fcs.pdf?dtrk=true

Patients with a Personal Welfare AttorneyThe Mental Capacity Act (2005) allows people over the age of 18 years of age who have capacity to make a Lasting Power of Attorney (LPA), by appointing a Personal Welfare Attorney who can make decisions on their behalf once capacity is lost. Before relying on the authority of this person the healthcare team must be satisfied that:

The patient lacks capacity to make the decision A statement has been included in the LPA specifically authorising the welfare attorney to

make decisions relating to life-prolonging treatment The LPA has been registered with the Office of the Public Guardian. The website is

http://www.justice.gov.uk/about/opgOffice of the Public GuardianPO Box 16185BirminghamB2 2WH Phone number: 0300 456 0300 - Phone lines are open Monday - Friday 9am - 5pm (Except Wednesday 10am - 5pm)Fax number: 0870 739 5780E-mail: [email protected]

The decision being made by the attorney is in the patent’s best interests.

The role of the Personal Welfare Attorney is to inform the decision making process, not to be the decision maker. They cannot demand treatment that is clinically inappropriate.

Patients without a Personal Welfare Attorney but who do have family or friendsWhere a patient has not appointed a personal welfare attorney or made an advance decision, the treatment decision rests with the most senior clinician in charge of the patient’s care. Where CPR may re-start the patient’s heart and breathing for a sustained period, the decision as to whether CPR is appropriate must be made on the basis of the patient’s best interests.

In order to assess best interests, the views of those close to the patient should be sought, unless this is impossible. The purpose of this discussion is to determine any previously expressed wishes and what level or chance of recovery the patient would be likely to consider of benefit, given the inherent risks and adverse effects of CPR. These considerations should always be from the patient perspective and only relevant information should be shared to ensure confidentiality standards are maintained.

In reaching a decision the Mental Capacity Act (2005) requires that best-interests decisions must include seeking the views of anyone named by the patient as someone to be consulted, anyone engaged in caring for the person or interested in the patient’s welfare. Under the Act, all healthcare personnel, for example doctors, nurses and ambulance crew, must act in the best interests of a patient who lacks capacity.

In these circumstances, it should be made clear to those close to the patient that their role is not to take/make decisions on behalf of the patient, but to help the healthcare team to make an appropriate decision in the patient’s best interests. Relatives and others close to the patient should be assured that their views on what the patient would want will be taken into account in decision-making but that they cannot insist on treatment or non-treatment.

Patients without a Personal Welfare Attorney and no family or friends Where a patient has no family or friends, no Personal Welfare Attorney and no advance decision has been made, the most senior clinician in charge of the patient’s care will make a decision in the patient’s best interests.


mailto:[email protected]

http://www.justice.gov.uk/about/opg

If the DNACPR is a clinical decision, and it is clear that CPR would not restart the patient’s heart or breathing, then this is made by the doctor acting in the patient’s best interests and documented on the DNACPR Record Form (Appendix 1) with an explanatory statement detailing the decision making process.

The Mental Capacity Act (2005) requires that an Independent Mental Capacity Advocate (IMCA) is involved any decisions about “serious medical treatment” where a patient has no family or friends, no Personal Welfare Attorney and no advance decision. For DNACPR decisions based on a balance of benefit versus burden the decision should be discussed with an IMCA. However if an IMCA is not available when required (e.g. weekends, out of hours) then the DNACPR decision should be made and documented on the DNACPR Record Form with a explanation why the IMCA was not involved documented in the patients notes. The decision should then be discussed with the IMCA at the first available opportunity as part of the decision making process.

The contact details for the IMCA Service in Portsmouth can be obtained from the South of England Advocacy Project website www.seap.org.uk


http://www.seap.org.uk/