Why is an integrated DNACPR policy needed?
Cardiopulmonary resuscitation ( CPR) is a treatment that could be attempted on any individual in whom cardiac or respiratory function stops. Such events are inevitable as part of dying and thus, theoretically, CPR could be given to every patient when they die. It is therefore essential to identify patients for whom cardiopulmonary arrest represents the terminal event in their illness and for whom CPR would be inappropriate because it will not work and/or is not wanted by the patient.
The aim of CPR is to restore spontaneous breathing and circulation in a way that is sustainable for that patient. As with any treatment, CPR should only be offered if there is a clear expectation that its aim can be achieved.
Where it is clear that CPR would not be successful (i.e. would not achieve sustainable spontaneous breathing and circulation) it should not be offered. There is a common lay-public misconception, possibly fuelled by media coverage, that CPR is always a potential life-saving treatment and that patients always have the right to be offered this treatment. Where it is clear in advance that CPR would not be successful it is essential that the information that CPR cannot be offered is clearly and sensitively shared with patients unless it is judged that the conversation would cause physical or psychological harm. Where a patient lacks capacity to engage with this conversation relatives/relevant others (those close to the patient) must be informed without delay where that is practicable and appropriate. A clinical decision that CPR will not work should be sensitively explained as part of a wider person-centred conversation about the patient's goals of care in the context of their current illness, and realistic expectation about future deterioration and dying.
It is also essential to identify those individuals who would not want CPR to be attempted in the event of an arrest and who competently refuse this treatment option. Some people may wish to make an advance healthcare directive about treatment (such as CPR) that they would not wish to receive in some future circumstance. Such directives must be respected as long as the decisions are informed, current, made without undue influence from others, and clearly apply to the current clinical circumstance.
This policy is intended to prevent inappropriate, contraindicated and/or unwanted attempts at CPR which are of no benefit and may cause significant distress to patients and families. A death managed with inappropriate CPR treatment is undignified and highly traumatic. When a patient dies at home or in a care home, an inappropriate CPR attempt may also involve the Scottish Ambulance Service paramedics and even the police, which can add greatly to the distress of the families and be upsetting for all those involved. This policy supports the wider aim of ensuring that a person's goals of care are known and respected at the end of life irrespective of whether they are being cared for in hospital, a hospice, a care home or in their own homes.
There is often confusion and uncertainty regarding CPR and the process of making advance decisions in which CPR will not be attempted. A consistent approach to decision-making, documentation and communication will help to avoid misunderstandings which can lead to harmfully distressing incidents for patients, families and staff. A single, integrated and consistent approach to this complex and important part of good end of life care is essential for all patients across Scotland.
In 2010, in response to a specific recommendation from the Public Audit Committee (following the Audit Scotland publication "Review of Palliative Care Services in Scotland"), the Scottish Government developed and implemented a national integrated policy "Do Not Attempt Cardiopulmonary Resuscitation ( DNACPR) Decision Making and Communication".
In 2016, this policy was reviewed to reflect feedback and changes in the national good practice guidance (Decisions Relating to Cardiopulmonary Resuscitation - guidance from the British Medical Association, Royal College of Nursing and the Resuscitation Council ( UK) - 2016). The policy also confirms the guidance within "Treatment and care towards the end of life: Good practice in decision-making" from the General Medical Council (2010). This policy takes into account relevant legal changes resulting from recent case law including; Montgomery vs Lanarkshire Health Board Scotland 2013 ( https://www.supremecourt.uk/cases/uksc-2013-0136.html); Tracey v Cambridge University NHS Trust and the Secretary of State for Health. ( https://www.judiciary.gov.uk/wp-content/uploads/2014/06/tracey-approved.pdf); and Winspear vs City Hospitals Sunderland NHS Trust ( http://www.bailii.org/ew/cases/EWHC/QB/2015/3250.htm)
Using the integrated DNACPR policy
The advice in this policy should be used in conjunction with the revised NHSScotland DNACPR form, decision-making framework and patient information leaflet, which can all be found within and appended to this policy. The purpose of the policy is to provide guidance and clarification for all staff working within NHSScotland regarding the process of making and communicating decisions about CPR. Further information is available at http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/peolc/DNACPR. It is a duty of care to ensure that, as far as possible, an advance DNACPR decision is communicated in a way that rapidly informs the emergency decisions of healthcare professionals when a patient's pulse and breathing have stopped. A consistent and instantly recognisable document is essential and the NHSScotland DNACPR form is recommended as best practice. An advance DNACPR decision can also be indicated within the electronic Emergency Care Summary using the Key Information Summary ( KIS  ). Services involved in the assessment of acutely unwell patients in the community or in hospitals should ensure that all frontline staff has access to, and knowledge of the KIS.
For children and young people, the wider anticipatory care document contained within the Children's and Young Person's Acute Deterioration Management ( CYPADM  ) policy is more relevant and appropriate to use for communicating advance decisions on emergency treatment and care such as CPR. However, it is acknowledged that there may be patients for whom use of the CYPADM remains appropriate well past the 18th birthday.
When a decision about CPR is discussed, made and recorded, clinicians should try to be clear about the basis for the decision. For example, it may be made with and/or for:
1. A person who is at an advanced stage of dying from an irreversible condition, so CPR is contraindicated.
2. A person who has advanced illness and deteriorating health such that CPR will not work.
3. A person for whom CPR is a treatment option with a poor or uncertain outcome.
4. A person for whom CPR is quite likely to restore them to a quality of life that they would value.
In the first two of these CPR will not be successful and should not be offered or attempted. In the third and fourth, the wishes of the patient are paramount. In the context of an acute illness or acute exacerbation or relapse of a chronic condition, consideration of an anticipatory decision about CPR should prompt also consideration of what other supportive treatments or higher-level care may or may not be needed by, wanted by or appropriate for each individual patient. There should be early involvement of senior, experienced clinicians in decision-making in such situations.
Decisions relating to CPR - guidance from the BMA, RC( UK) and RCN 3rd ed (1st revision) 2016
Within this policy, the term "Do Not Attempt Cardiopulmonary Resuscitation" ( DNACPR) is used rather than "Do Not Attempt Resuscitation" ( DNAR) to help clarify for patients, families and professionals that this policy refers solely to cardiopulmonary resuscitation ( CPR) in the event of a cardiac or respiratory arrest. DNACPR is also specifically used rather than "Allow Natural Death" (AND) as it does not mean "do not treat". Indeed, other aspects of emergency care e.g. analgesia, antibiotics, suction, treatment of choking, treatment of anaphylaxis, non-invasive ventilation or even treatment in an Intensive Treatment Unit ( ITU) may be appropriate for patients with DNACPR decisions. Where patients are admitted to hospital or a hospice acutely unwell, or become medically unstable in their existing home or community healthcare or social care setting, their CPR status should be considered as soon as is reasonably possible if a cardiac or respiratory arrest can be anticipated. It is both good practice and may be legally required to consider and communicate CPR decision-making within the context of exploring goals of care and appropriate levels of escalation of treatment with the patient, any welfare attorney/welfare guardian or others close to the patient. Sometimes patients are not medically unstable, but it is clear that advanced illness, significant frailty and/or co-morbidity are such that they are at risk of deterioration and therefore death would not be unexpected. For these patients, it is important to consider, discuss and document advance decisions about goals of care and treatment plans which must include a decision on whether CPR should be attempted. An advance DNACPR decision should be recorded in the KIS along with details of other available treatment options when the person is in, or being discharged back to, a community environment.
A number of Health Boards are using and developing forms and templates for documenting options for emergency treatments or levels of care (e.g. "ward level care", "intensive care", etc.) that would or would not be appropriate and/or wanted in a sudden acute deterioration situation. It is recommended that the NHSScotland DNACPR form be used to complement any locally developed Anticipatory Care Plans ( AnCP), Treatment Escalation Plans ( TEP) or Emergency Care and Treatment Plans ( ECTP).
When no explicit decision has been made about CPR before a cardiopulmonary arrest occurs, and the express wishes of the patient are unknown, it is presumed that staff will initiate CPR. However "there will be some people for whom attempting CPR is clearly inappropriate; for example, a person in the advanced stages of a terminal illness where death is imminent and unavoidable and CPR would not be successful, but for whom no formal CPR decision has been made and recorded. Also, there will be cases where healthcare professionals discover patients with features of irreversible death - for example, rigor mortis. In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies".  It is essential to document clearly in the clinical notes a detailed account of the assessment and rationale for the clinical decision not to attempt CPR in this situation, and clinicians must be supported to do this by colleagues and line managers.
Throughout this document, the term "patient" is used to refer to the person for whom the CPR decision-making process is intended but it is acknowledged that this policy may be relevant for people in community care and residential settings who may not necessarily regard themselves as "patients".
Throughout this document, the term "relevant others" is used to describe those close to the patient such as the patient's spouse, partner, relatives, carers, named person, representative, advocate, welfare attorney or welfare guardian.
Email: Elizabeth Gourlay, email@example.com