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Imagine you are the ED middle grade in a busy unit overnight. There are 80 patients in the department and there is little flow to the acute medical unit (AMU) which is already at capacity. Patients are being bedded down in the department and there is a growing backlog of medical patients awaiting assessment by the medical team. Amidst the mayhem your SHO asks you for advice about a patient she’s just seen.
Trauma is such a sexy topic. Add children and… well… feelings can change.
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In this podcast and discuss DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) and explore when and how decisions should be made. They also explore some of the challenges about decision-making and delve into the evidence and guidance currently available.
What is DNACPR?
A medical decision made by an appropriately trained and experienced clinician that is communicated to the patient and their family. It concerns what will happen to the patient in the event of a cardiac arrest. It does not include any guidance on treating the patient as they deteriorate – patients should receive all active care unless otherwise stated, documented and communicated.
Is it appropriate to make this decision in the ED?
Make a decision as early as it is appropriate. There are challenges to this in the Emergency Department: we have a lack of information and can be pressed for time. The Emergency Department environment is not ideal to be having these discussions. In saying that, if we have the information in front of us and know the patient’s wishes, then it may be appropriate to decide and complete the form.
What guidelines are available?
Every acute Trust has its own guidance. These are worth a read as they include explanation of local paperwork.
What are the practical implications of making a DNACPR decision?
You are required as a doctor to act in the patient’s best interests. Therefore, if you believe the patient is going to deteriorate, you need to make a decision when it is appropriate to do so. There are societal, cultural and personal challenges to this – people don’t tend to talk about death and you need to overcome your own personal attitudes to death and decision-making prior to coming to a clinical decision. It is then up to you to communicate this to the patient and their relatives.
Unrealistic expectations of CPR:
The television and film industry would have people belief that we are “heroes” and succeed in resuscitating a high proportion of patients who have a cardiac arrest – this is far from reality. A recent article in the Guardian addressed this.
What is the evidence for all of this?
Much has been written about DNACPR over the years. In the past couple of years there are a few papers worth reading.
Court Cases:
There have in recent years been a couple of extremely important court cases surrounding this issue.
Tracy judgement – brought by the husband of Janet Tracey against Cambridge University Hospitals NHS Foundation Trust and the Secretary of State for Health regarding the placement of a DNACPR order in his wife’s notes.
Winspear judgement – brought by the mother of Carl Winspear against City Hospitals Sunderland following a DNACPR decision that was made and not communicated with her.
This article from the BMJ – Cautionary tales about DNACPR nicely summarises some of the issues discussed in this podcast.
Take home messages:
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One of the greatest challenges for emergency medicine is to recognise paediatric sepsis. There are several myths surrounding paediatric sepsis, all of which are debunked in this article.
This talk hopes to explore how we make decisions in the ED, why it’s often difficult in a time poor, information light setting and gives some strategies for how we might analyse and improve our performance.
The final afternoon session on the first day of RCEM addressed Hot Controversies within the speciality and was chaired by Professor Jason Smith.
For those of you who weren’t able to attend and for those of you who want to listen again to some of the great talks, this month we’ll be bringing you some of the superb plenary sessions on the podcast.
Rom Duckworth is a Fire Captain and paramedic educator from the greater New York City area. A prehospital clinical practitioner, Rom has interest and expertise in human factors, especially mission critical communications.
As the opening speaker in the “Marginal Gains” session on Day 3 of RCEM15, Paul Jarvis offered a very practical overview of Rapid Assessment schemes in UK Emergency Departments – including an honest appraisal of why they so often fail.
When you assess your patient you need to take a good focussed history, make a thorough examination focussing on evidence of respiratory failure/distress and make an assessment to the hydration status of the child, whilst thinking about and taking steps to discount other diagnoses such as pneumonia and Viral Wheeze.
