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.
- Decisions related to cardiopulmonary resuscitation 2014: Resuscitation Council UK document which covers all aspects of DNACPR decision-making.
- GMC “Treatment and Care towards the End of Life”
- National End of life Care program “DNA CPR decision who decides and how”
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.
- DNACPR orders: a systematic review of the barriers and facilators of decision-making and implementation concludes that most people who die in hospital have a DNACPR. It explores the key triggers for decision-making and consequences of the decision.
- Characteristics and outcome of patients with DNACPR orders in an acute hospital: an observational study is interesting as it found that 83% of patients who had a decision made about them were dead within 1 year of the decision.
- Two decades of British newspaper coverage regarding do not attempt CPR decisions: lessons for clinicians gives an interesting insight into the challenges we all face over media coverage of the decisions we make.
- NCEPOD 2012 “time to intervene” looked at what happens to patients who are admitted to hospital and have a cardiac arrest. They recommend we should consider CPR status in every single acute admission – for the majority of patients they will be for full active treatment but we need to consider in all to ensure we do not attempt resuscitation on patients for whom it is not appropriate.
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:
- Consider, and aspire to make, a decision in all acute admissions
- Discuss with patient
- Ensure you discuss with family, don’t delay this – make every effort to contact them
- Remember that avoiding the decision is not in the patient’s best interests, and that we all have personal barriers as well as professional challenges that make these decisions difficult.
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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.
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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.