Authors: Charlotte Davies / Editor: Nikki Abela, Liz Herrieven /  Codes: ELC3, RP3, SLO7, SLO8, SLO9 / Published: 18/05/2021

 

DNA CPR or “do not attempt resuscitation” decisions are confusing to many. If discussed sensitively and correctly, they make a huge huge huge immeasurable difference to the hospital stay of the patient, and their relatives. There’s lots of confusion around best practice and the law, and here we explore a few of the common myths and perceptions, as we’ve found many of our senior doctors are confused.

  • Which patients should we talk about DNA CPR with?

That’s not an easy question to answer – arguably, everyone who attends ED! I think a reasonable framework is to ask yourself two questions

  1. “would I be surprised if this patient died in the next year” – if no, a DNA CPR should be discussed before the patient leaves the hospital.
  2. “Would I be surprised if the patient died in the next few days” – if no, I think DNA CPR should be discussed in the emergency department.

How do you know your patient is dying? Well, your gut feeling is often very accurate and real – the “surprise” gut is often right. We offer some further features about the phases of dying in our “Dying Matters in the ED” blog or podcast segment, also duplicated in theRCEM EoL toolkit. Looking at these descriptors you can see a person shouldn’t be DNA CPR just because they’re old, and they shouldn’t be for CPR just because they’re young.

Is the emergency department the right place to have this discussion? That is always going to depend on everything. Privacy is often lacking on the ward, as much as it is in ED. The admitting team are often as apprehensive about discussing DNA CPR as the ED team. It takes a similar amount of time (often less than you’d expect) whether it’s ED or the medics.

But not all patients are ready to have that discussion – and for some, the emergency department is the place to give the warning shot that the admitting team can build on.

“I think you’re sick / poorly enough to die. Have you talked about any wishes with your family”?

For some – the imminently dying – rapport and conversations have to be had swiftly, and in the emergency department as they might influence further care.

For patients discharged, it’s hard to initiate end of life discussions, but it could be appropriate. “I notice you’ve had four falls in the last year, and I’m worried one of these falls will be your last. Have you thought about that?” Patients are often wiser than you think. These are “escalating the possibility” of dying, as discussed on twitter here by Kathryn Mannix. 

I always think DNA CPR should be discussed with the “borderline” patients – those in whom you’re not sure whether to admit or discharge, and definitely with the ones you want to admit who don’t want to stay! I remember discharging a patient with a HR of 120, CRP of 300 on oral antibiotics because she was adamant she didn’t want to stay in hospital – but asking her what her thoughts around death and dying were, gave us and her daughter a chance to express our fears, and confirm she wasn’t keen on CPR, but thought NIV might be useful.

  • What does DNA CPR mean? 

Literally, DNA CPR means do not attempt cardio-pulmonary resuscitation. I know we’re labouring the point, but it means if this person has a cardiac arrest (their heart stops) we should not try and restart it with chest compressions, drugs, or anything else we can think of.

It does not mean we should stop treating the problems likely to cause a cardiac arrest. If a DNA CPR is in place, we can still lower the potassium and give the calcium gluconate to stabilise the myocardium. We can still give a fluid bolus, or even some vasopressors. We can give analgesia and anxiolytics. We can even intubate a patient and they can be looked after in intensive care – but if they have a peri-induction cardiac arrest we will not perform CPR.

In some patients CPR is not appropriate, but ITU might be or ITU might not be. This means many hospitals now have a treatment escalation plan where the “ceiling of care” is discussed, documented and decided. This might be:

for full treatment, including CPR

not for CPR, for full active treatment otherwise

for ward based ceiling of care

for comfort care

Ward based ceiling of care means all treatments can be given up to the point of going to intensive care. Does it mean you can’t give a patient metaraminol because that’s an ITU treatment? Probably. This decision is normally made because it is felt the trauma of ITU would be too much for a patient, and unlikely to confer any benefit.

For most people, ward based care would include non-invasive ventilation.

Comfort Care is focussing everything on keeping the patient comfortable. Observations – probably not worth doing as they’re not going to change anything. ABGs – probably aren’t keeping the patient comfortable.

Can you provide comfort care alongside a ward based ceiling of care? Many of the principles are exactly the same, and we should think of the patient alongside everything we do. Pneumonia can be treated with antibiotics, IV fluids, oxygen (traditionally considered active care) alongside a syringe driver with small amounts of morphine and midazolam to aid the dyspnoea (traditionally considered comfort care). It’s really the personalisation of care to help the patient and their family reach their goals.

Documentation of this could be on a TEP form, or a RESPECTform.

  • What is a RESPECT form?

A RESPECT form is the name given to a form used to document a patient’s wishes. It’s not legally binding and can be changed at any time. This is the place where conversations between families and HCPs can be summarised – dying in hospital or home, religious considerations, music playing etc. 

A TEP is similar but slightly more treatment focussed. The treatment escalation plan prompts you to think about the goals of care, and whether intensive care is suitable, whether non-invasive ventilation is suitable, and whether repeated cannulation attempts etc. are suitable. 

  • Who Decides a patient is DNA CPR?

A DNA CPR is a medical decision, made by the team looking after the patient. In many hospitals this needs to be a decision made by a registrar or Consultant.The family and the patient should be strongly involved in this decision, as it is only with their involvement that you can get a picture of the patient, and whether DNA CPR is in their best interests.

The law is slightly tricky as if a patient has made a capacitous decision to refuse CPR, they are allowed to do so – either as an advanced directive, or as a current decision. Family are not allowed to refuse CPR on behalf of a patient – but they can and should be allowed to advocate for the patient’s likely wishes.

A patient and their family can not demand CPR.

This means that when having the discussions, it is important to be really clear about what CPR is and what it is not, and that you are inviting an opinion, not a decision. In case of disputes and disagreements, it’s always worth getting a second or third opinion. Although the family can not demand CPR is performed, you do not want to compound their imminent grief any further by causing distress around this decision. There’s normally time for more communication, and more discussion. If there’s not time, and the family have strongly objected to a DNA CPR, the majority of the time I would start CPR to give the family the time to come to terms with the deterioration of their loved one.

  • What about patients with learning disabilities?

During the COVID-19 pandemic, people with learning disabilities have been disproportionately affected. LeDeR, the Learning Disability Mortality Review programme, which aims to review the deaths of all those with LD, over the age of 4 years, in England, found many reasons for this. Keeping things general, only 56% of those who they reviewed in 2020 received care which could be described as meeting or exceeding good standards of care. Many had DNA CPRs in place with often only “learning disability” or “Down syndrome” listed as reasons not to attempt resuscitation. LeDeR, and the LD community, are very clear that learning disability or Down syndrome alone are not reasons to decide against resuscitation. Many people with these conditions lead full and happy lives, despite their challenges. As is the case for anyone else, the decision to resuscitate or not must be made based on the patient’s wishes, their pre-morbid health and the likelihood of survival of the current illness. And, as is the case for anyone else, whether for resuscitation or not, care received should be of the highest quality possible.

  • How do I have the conversation?

If you’re not comfortable or familiar with having these conversations bring someone with you who is. It doesn’t have to be a Doctor – our HCAs are much better at these peri-death conversations, and would be my preferred buddy. 

If you’ve got time, you could just give a warning shot and give the patient a copy of the death and dying booklet from Age UK here that focuses more on DNA CPR than ITU care, with this letter from Matt Morgan, that nicely highlights priorities of care. Have a look here for more printable posters from Linda Dykes that rephrase things into “allow peaceful death”. There are other resources hereorhere (see twitter) for some framework videos. Another twitter discussion asked if we should diagnose dying, or just escalate the possibility of dying.

Many of us are starting to have to deliver bad news over the telephone, which is not something we’re comfortable with. There’s a twitter thread discussing it here, with this prompt sheet, and this crib sheet being really useful, with some tips about dealing with bereaved children here. There’s some freely available simulated discussions available via twitter here and the #TalkCPR on twitter has lots of useful resources. 

 

 

  • What else?

It’s good to talk about organ donation, preferred place of death and spiritual needs. There are lots of different cultural practices and some can be hard to sort in a hurry. There’s a guide available here

  • When should I ignore a DNA CPR? 

This is really hard but if you’re doing a procedure that might cause a reversible cardiac arrest, it’s worth discussing with the patient. Choking on porridge – reversible. Anaphylactic arrest to your antibiotics – possibly reversible. Respiratory arrest secondary to an over zealous sedation – reversible. If you think a DNA CPR has made in error and can’t find any detailed documentation or reasoning I’d ignore it. 

 

  • International Medical Graduates

DNA CPR discussions are different for everyone, and overseas doctors may need extra help in navigating these circumstances. Abhishek Sharma explains more: 

I moved to the UK not so long ago in 2019 and joined the NHS as a Senior Clinical Fellow in the Emergency Department (ED). I was quite new to the country and therefore spent the first couple of weeks in orienting myself with the system while parallelly shadowing an experienced registrar. This induction period was very helpful in kicking off my journey in the NHS, but there are many ‘softer’ aspects of my job which usually throws me off guard.

For instance, once an old lady with dementia called me politely to her bed side and whispered, “I need to spend a penny”. I was clueless at first and responded her by saying that she is ill, and it is not wise for her to walk outside at this moment. Further, I added that if she wanted, I could assign someone to fetch for whatever is that she needed. Unimpressed by my offer, she kept repeating “I need to spend a penny.” Later, when I was speaking to one of the nursing staff, I did mention about the lady’s bizarre wish to spend a penny to which she funnily replied that the lady was meaning to go to the toilet. Lamenting at my absurdity, I rushed to her, apologised, and offered help. Many such similar ‘moments’ caught me like a rabbit in the headlights. I do realise that sometimes foreign accents would be difficult for the locals to comprehend. Therefore, as a beginner in this country, it becomes equally essential to learn the culture and colloquialism which can put our patients at ease.

I would like to illustrate another unique experience. Over the past few months, I have really begun to enjoy my time in ‘Resus’ and have also offered to take up additional shifts. I was comfortable working in ‘Resus’ as it was a straightforward disposal process on most occasions i.e. Resuscitate & Start initial management & Refer to Speciality. On one of my shifts, the ED consultant inquired about my plan regarding a sick elderly patient. My response was “Frail elderly gentleman with chest sepsis, doing very poorly, I have started management with antibiotic, fluids, monitoring, and will refer to the Medics now, don’t think he is going to make it.”. Nodding to this, the Consultant asked me what his ‘Resuscitation Status’ was and if I had discussed with the patient regarding the treatment escalation plan and the resuscitation process. I was caught off guard again because it was a different practice back home. I knew what he meant, but such a sensitive discussion would be taking place with the patient’s family rather than the patient himself. However, in this case, I had to walk up to the patient who was just wheeled in a few minutes ago, to let him know that he may be nearing his death and we needed to get his consent regarding resuscitation. I did ask for support from my colleagues since it was my first time and eventually it went well.

This was indeed a great learning experience for me. It is not easy to have a resuscitation discussion with the patient, however, I realised why it is so important. It is not for the sake of protocol or compliance, but it is the patient’s right to know about their health condition and they deserve to know about their likely death. End of the day, it is their body and health, and we are just servants trying to do the best we can to save them. To conclude, it comes to my understanding that the job of a doctor is not just ‘clinical advise’ but it is indeed an all-encompassing pursuit that requires an equal amount of technical and people management skills.

Hopefully this blog has answered some of your questions, and provided a useful framework to consider. We’re always happy to be contacted if you have further questions, resources, tips or tricks.

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References and Links