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CARDIOPULMONARY RESUSCITATION AND DO NOT ATTEMPT RESUSCITATION

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					              CARDIOPULMONARY RESUSCITATION AND
                 DO NOT ATTEMPT RESUSCITATION
Version number                   2
Name and title of originator/    Bonita Burrow, Clinical Projects
lead author                      Mairi Rider, Modern Matron
                                 Sarah Leggett, Asst Director of Quality & Risk
                                 Rosemary Carroll, Clinical Lead
Contact details of originator/   bonita.burrow@banes-pct.nhs.uk
author                           Tel: 01225 831640
                                 mairi.rider@banes-pct.nhs.uk
                                 Tel: 01225 832383 Bleep 049
                                 sarah.leggett@banes-pct.nhs.uk
                                 Tel: 01225 831866
                                 Rosemary.carroll@banes-pct.nhs.uk
                                 Tel: 01225 831
Name of Lead Executive/          Rhona MacDonald
Director/Manager                 Chief Executive
                                 Rhona.mcdonald@banes-pct.nhs.uk
* Ratified by (include           Community Healthcare Services Committee – Sept
ratification date)               2009
Date issued                      October 2009
Review date                      September 2011
Expiry date (9 months after
                            June 2012
review date
Links to standards and
performance indicators
Applicable to (shade appropriate box)                Target audience
Community Healthcare Staff       Yes       No        All Staff involved in
Public Health Staff              Yes       No        All staff involved in
Commissioning Staff              Yes       No

This document can only be considered valid when viewed via the Trust’s
website. If this document is printed into hard copy or saved to another
location it is your responsibility to check that the version number on your
copy matches that of the one online.

* Note for documents that apply to both Commissioning and Community
Healthcare Staff, these must be ratified by the appropriate committee/group within
Commissioning and Community Healthcare Services



Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 1 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
CONSULTATION PROCESS

Key individuals involved in developing this document (main authors)
Name                      Designation
Bonita Burrow             Clinical Project Manager
Mairi Rider               Modern Matron
Sarah Leggett             Asst Director of Quality & Risk
Rosemary Carroll          Clinical Lead

Circulated to the following individuals for consultation

Name                          Designation
Nikki Woodland                Acting Modern Matron
Danny Street                  Acorn Resuscitation Trainer and Advisor
Andrew Riches                 B&NES Training Department

Circulated to the following group(s) for consultation prior to ratification

Name of Group                                                        Date
Clinical Standards Group                                             December 08
Clinical Standards Group                                             April 09
Clinical Standards Group                                             June 09

Circulated to the following group(s) for final approval prior to ratification

Name of Group                                                        Date
Policy Advisory Group

Circulated to the following group(s) for ratification
Name of Group                                                        Date
Community Healthcare Services Committee                              Sept 09


VERSION CONTROL

Version
        Updated By            Updated On          Description of Changes
  No
                                                  Incorporation of DNAR policy with
   2       BB,MR,SL, RC       10th March 2009
                                                  Resuscitation Policy
                                                  Incorporation of comments from
   2       BB, SL, DS         27th May 2009
                                                  members Clinical Standards Group
                                                  Incorporation 2 further sets
   2       BB, MR, CC         9th July 09         comments Clinical Standards
                                                  Group



Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 2 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
                Resuscitation Policy - Quick Read Summary
                   NHS B&NES has an obligation to provide an effective and efficient
                   resuscitation service and to ensure that staff receive training and
                   regular updating appropriate to their role. NHS B&NES also has an
                   obligation to ensure that an individual’s wishes are respected should
Introduction       they decide that they do not want to be resuscitated.
                   All persons covered by the policy (adult, older people and children) will
                   be presumed to be for resuscitation in the event of a sudden collapse
                   due to cardio-pulmonary arrest [CPR] unless a Do Not Attempt
                   Resuscitation decision has been made.
                   The purpose of the policy is to provide direction and guidance for
Purpose            resuscitation and provide guidance for staff about those individuals to
                   whom the ‘Do Not Attempt Resuscitation’ applies.
                   This policy applies to all patients, visitors and staff, should they have a
                   sudden cardio-pulmonary arrest, within NHS B&NES properties or
                   patients visited in the community. All clinical staff with regular direct
                   patient contact are affected by this policy and have responsibilities under
                   it.

                   The Community Healthcare Services Committee is responsible for
                   overseeing the provision of resuscitation services in NHS B&NES.

                   Directorate and Service Managers are responsible for the
                   implementation of the policy in their own areas
Duties &           Ward/Team Managers are responsible for ensuring that;
Responsibilities
                    • Staff have training
                    • Appropriate emergency equipment is in place
                    • There is a procedure /protocol for summoning the emergency
                       services.
                    • Complete an Adverse Event Form each time CPR is attempted

                   All staff hold responsibility to:
                      • Attend training in line with requirements as set out in the PCT
                         Training Matrix
                      • Report concerns to their line manager
                      • Initiate CPR in line with policy guidance
                      • Complete an Adverse Event Form each time CPR is attempted
                     •   All clinical staff should be able to recognise people in distress
                     •   Call for help / assistance
Resuscitation
Procedures           •   Initiate basic life support should be initiated
                     •   Call emergency services
                     •   Defibrillation must only be used by staff trained in this procedure
Do Not Attempt     All patients will be given cardio-pulmonary resuscitation (CPR) unless a
Resuscitation      clear entry has been documented in their care plan, or the person has
(DNAR)             recorded a wish not to be resuscitated through an advance decision,

Process for        All events to which a cardiac arrest team is summoned must be audited
Monitoring         (DoH HSC 2000/028)
Compliance with,
and the            Compliance with the organisation-wide Cardiopulmonary Resuscitation
Effectiveness of   Policy must be audited annually and reported to the Clinical Standards
this Policy        Group.

Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 3 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
Section                                  INDEX                                     Page No

          Consultation process and version control                                    2
          Quick Read Summary                                                          3
          Index                                                                       4
  1       Introduction                                                                6
  2       Purpose                                                                     6
  3       Definitions                                                                 6
          3.1     Resuscitation                                                       6
          3.2     Cardiopulmonary arrest                                              6
          3.3     Basic life support                                                  6
          3.4     Enhanced resuscitation skills                                       7
          3.5     Advanced life support                                               7
          3.6     Do Not Attempt Resuscitation                                        7
          3.7     Nurse/person in charge                                              7
          3.8       Anaphylaxis                                                       7
  4       Duties                                                                      7
          4.1     Duties within the organisation                                      7
          4.2     Approval of the resuscitation policy                                7
  5       Training strategy                                                           8
          5.1     General training recommendations                                    8
                  5.1.1      Clinical staff                                           8
                  5.1.2      Non-clinical staff                                       9
  6       The Emergency Team Response                                                 9
          6.1     Post-incident debriefing                                            9
  7       Resuscitation equipment replenishment and cleaning                          9
          7.1     Emergency Boxes                                                     9
          7.2     Defibrillator                                                       10
  8       Manual handling                                                             10
  9       Infection prevention and control                                            10
  10      Anaphylaxis                                                                 10
  11      Defibrillation                                                              11
  12      Do Not Attempt Resuscitation (DNAR)                                         11
          12.1      When to Consider a DNAR policy                                    12
          12.2      Making and management of DNAR Order                               13
                    12.2.1        Responsibilities                                    13
                                  Consultation and consideration when reaching
                    12.2.2                                                            13
                                  a decision
                                  Documentation and communication of the
                    12.2.3                                                            14
                                  DNAR order
                    12.2.4        Legal considerations                                14

Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 4 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
Section                             INDEX (cont’d)                                 Page No

          Process for monitoring compliance with and the
  13                                                                                  15
          effectiveness of this policy
          Process for reviewing, approving and archiving this
  14                                                                                  15
          document
  15      Dissemination, implementation and access to this document                   15
  16      References                                                                  15
  17      PCT Related Policies                                                        16


                                APPENDICES                                         Page No

          Resuscitation Council (UK) Basic Life Support
   A                                                                                 17
          Resuscitation Flowchart - Adults

          Resuscitation Council [UK] Basic Life Support
   B                                                                                 18
          Resuscitation Flowchart - Paediatric

   C      Healthcare professionals with a duty to respond – flowchart                19

   D      Equipment and resuscitation drugs (and accessories)                        20

   E      Weekly record for resuscitation equipment checks                           23

   F      Anaphylaxis flow chart                                                     24

  G       Do Not Attempt Resuscitation Order Sheet                                   25




Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 5 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
1.0    INTRODUCTION

Policy statement

NHS B&NES has an obligation to provide an effective and efficient resuscitation
service and to ensure that staff receives training and regular updating appropriate
to their role. NHS B&NES also has an obligation to ensure that an individual’s
wishes are respected should they decide that they do not want to be resuscitated.

This policy provides guidance for clinical practice and training for those with
responsibilities for resuscitation services within NHS B&NES. This Resuscitation
and Do Not Attempt Resuscitation policy follows the recommendations for clinical
practice and training in cardiopulmonary resuscitation published by the
Resuscitation Council (UK) [RCUK] (November 2005), and the British Medical
Association [BMA] and also the joint RCUK and Royal College of Nursing [RCN]
statement on Decisions Relating to Cardiopulmonary Resuscitation. It has been
written to promote compliance with National Health Service Litigation Authority
[NHSLA] Risk Management Standards (NHSLA, 2009), Health Circular 2000/028,
the Human Rights Act [1998] and the Mental Capacity Act 2005. User consultation
has also ensured that patients’ rights are central to decision-making on
resuscitation.

This document addresses the issue of cardiopulmonary resuscitation for all PCT
clinical staff in in-patient and community settings.

2.0    PURPOSE

The purpose of the policy is to provide direction and guidance for the
implementation of a high quality and robust resuscitation service and provide
guidance for staff about those individuals to whom Do Not Attempt Resuscitation”
applies. Also to ensure patients’ rights are central to decision-making on
resuscitation

3.0    DEFINITIONS

3.1    Resuscitation

The emergency treatment of any condition in which the brain fails to receive
enough oxygen.

3.2    Cardiopulmonary arrest

A combination of cardiac and respiratory arrest. The sudden and complete loss of
cardiac [heart] functions, which will be evident by the absence of any signs of
circulation. Also the complete cessation of breathing, where a pulse is still
present.

3.3   Basic life support

The initial assessment of a patient leading to a situation where airway
management, rescue breathing and chest compressions may be required.


Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 6 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
3.4    Enhanced resuscitation skills

This incorporates basic life support, the safe use of Automated External
Defibrillators (AED) and the use of other pieces of equipment such as suction,
airways, oxygen and pulse oximeters to further support staff to manage a patient
in cardiac arrest until such time as the patient is handed over to an appropriate
person (eg: doctor or ambulance service).

3.5    Advanced life support

This incorporates basic life support, the use of defibrillators and the use of further
skills including drugs and advanced airway management to further support a
patient in cardiac arrest until such time as the patient is handed over to an
appropriate person (eg: doctor or ambulance service).

3.6    Do Not Attempt Resuscitation

A directive made by a doctor that resuscitation of a patient should not be
attempted

3.7    Nurse/Person in charge

For in-patient areas, the senior nurse/person in charge is the person responsible
in the clinical area for the shift or part of a shift. In the community or outpatient
bases the visiting or on duty nurse/person takes the lead if a CPR situation
occurs.

3.8   Anaphylaxis

This is an acute systemic [multi-system] and very severe Type 1 Hypersensitivity
allergic reaction. This may occur after ingestion, skin contact, injection of an
allergen or, in some cases, inhalation.

4.0    DUTIES

NHS B&NES has an obligation to provide effective resuscitation to its patients and
appropriate training to its staff.

4.1    Duties within the organisation

It is the responsibility of the Clinical Standards Committee, Community Services
Healthcare Committee and senior managers to ensure policy distribution,
implementation and compliance throughout the organisation.

4.2    Approval of the resuscitation policy

The policy has been approved by the Clinical Standards Committee and ratified by
the Community Services Healthcare Committee and has been accepted as an
organisation-wide policy by the Board.




Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 7 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
5.0    TRAINING STRATEGY
The strategy for resuscitation training shall embody the statements and guidelines
published by the Resuscitation Council (UK) and the European Resuscitation
Council, incorporating the most recent updates to these guidelines (Appendices A,
B and C).

NHS B&NES will provide sufficient and appropriate resuscitation training for each
of the main staff groups i.e.: adult staff groups and paediatric staff groups.
Specific guidelines for resuscitation training are detailed in B&NES Training
Policy.

5.1    General training recommendations
5.1.1 Clinical Staff
a) Clinical staff must undergo yearly regular resuscitation training to a level
   appropriate to their expected clinical responsibilities eg: in-patients,
   Community, Lifetime

b) All resuscitation training will follow the current guidelines published by the
   Resuscitation Council (UK).

c) Clinical staff must be trained to recognise patients at risk of cardiopulmonary
   arrest.

d) All clinical staff employed by NHS B&NES must be trained to recognise that
   the cardiac arrest has occurred. They must all be trained in how to summon
   help and, if indicated, to start CPR. See resuscitation flowcharts for adults
   (Appendix A), paediatrics (Appendix B), and Healthcare Professionals with a
   Duty to Respond e.g. Lifetime; Health Visitors; School Nurses; Walk In Centre
   and Minor Injury Unit [Appendix C].

e) Sufficient staff will be trained to use a defibrillator (automated external
   defibrillator – AED) to enable attempted defibrillation within three minutes of
   collapse of a patient anywhere on the community hospital sites. This training
   is included as a module alongside basic life support (BLS) for those who
   require it. The use of oxygen must be incorporated into the training for in-
   patients and out-patients and Lifetime staff.

f) All clinical staff to attend anaphylaxis training yearly

g) The Training Department will maintain a database of all staff trained and will
   audit uptake of training annually, and the accessibility and function of the
   equipment used. This includes:
     • Numbers of staff attending training
     • Numbers of staff who did not attend (DNA)
     • Any issues relating to the quality of training provided
     • Any issues relating to the competence of staff to carry out resuscitation
     • Any issues relating to the equipment, its suitability and reliability
     • Any other relevant factors


Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 8 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
     • The Training Department will supply managers with reports of staff who
       have attended training and those that were booked but did not attend
       training.
h) Competency is not currently recorded, but staff are required to demonstrate
   CPR on a manikin for a period of two minutes, together with the use of an
   appropriate resuscitation aid. Records of attendance will be held by
   managers.

5.1.2 Training for Non-clinical staff

All hospital, community and administrative staff with face to face, regular contact
with patients must be trained in basic life support (BLS).

6.0      THE EMERGENCY TEAM RESPONSE

NHS B&NES does not have a specific emergency team [CRASH Team] as it is
not an acute trust. All clinical staff on the wards or in out-patients must be trained
in the identification of critically ill patients and the use of physiological observation
charts to enhance decision making and escalation of care.

In all instances where CPR is commenced a member of the team must call 999 to
request an emergency ambulance, advising basic life support has been instigated,
and transfer of patient to an acute hospital.

•     Ring 4999 – St Martin’s Hospital or direct from ward
•     Ring 999 – elsewhere
•     Liaison with the ambulance services with details of patient to hand.
•     Full and complete handover of care
•     Informing relatives

Staff in the community must ensure help is summoned by dialling 999.

6.1      Post-incident debriefing

The department’s senior nurse will meet with the team involved and carry out
critical incident debriefing, endeavouring to support those involved. A “lessons
learnt” report to be written up, shared amongst the team and copy sent to the
Lessons Learned Group for learning and audit purposes.

7.0      RESUSCITATION EQUIPMENT, REPLENISHMENT AND CLEANING

7.1 Emergency Boxes

In community hospital in-patient settings, the emergency boxes must be
maintained in a state of readiness at all times. Boxes are filled, checked and
sealed by pharmacy and labelled to identify the expiry date of drugs within the box
[appendix D]. Emergency boxes must be checked by a qualified member of staff
at least once every 24 hours to check sealed and in date, and immediately
following conclusion of a resuscitation event.

Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 9 of 26   Version: 2   Date of Issue: October 2009   Date of Review: September 2011
7.2 Defibrillator

The defibrillator and equipment must be checked daily [appendix E]

8.0      MANUAL HANDLING

In situations where the collapsed patient is on the floor, in a chair or in a restricted/
confined space, then CPR must be commenced and continued until paramedics
arrive, if it is safe to do so. The organisational guidelines for the movement of the
patient must be followed to minimise the risks of manual handling and related
injuries to both staff and the patient (See B&NES Manual Handling Policy. Please
also refer to the Resuscitation Council (UK) statement which can be found at
http://www.resus.org.uk/pages/safehand.htm.

9.0      INFECTION PREVENTION AND CONTROL

Infection control is integral to safe practice when carrying out resuscitation.
Whilst the risk of infection transmission from patient to rescuer during direct
mouth-to-mouth resuscitation is extremely rare, isolated cases have been
reported. It is therefore advisable that direct mouth-to-mouth resuscitation is
carried out using a face mask.

•     In-patient and out-patient localities in B&NES have wall-mounted pocket
      masks.
•     Community staff will be issued with portable resuscitation barriers. The Trust
      will ensure that where necessary equipment including resuscitation face
      shields or pocket masks are provided.
•     All single use items/disposable equipment/sharps used for the purpose of
      resuscitation must be disposed of in accordance with local clinical waste and
      sharps disposal policy.
•     Staff must adhere to standard prevention and control measures as reference in
      B&NES Infection and Control Policy [covered in induction for new staff and
      annual infection control updates].
•     If staff do not have a mask to hand and have resuscitated a patient contact
      must be made with the Occupational Health Department at the Royal United
      Hospital for advice and support [contact 01225 424064].

10.0     ANAPHYLAXIS

•     The management of suspected anaphylaxis/anaphylactoid reactions must be
      conducted in accordance with the Resuscitation Council (UK) guidelines for
      the management of anaphylaxis, which has been adopted as NHS B&NES
      policy http://www.org.uk/pages/reaction.pdf
•     Flowchart for the emergency treatment of anaphylactic reactions detailed in
      The Resuscitation Council [UK] guidelines for the management of anaphylaxis
      is outlined in appendix F.
•     B&NES NHS has a Patient Group Direction for adrenaline, but for the
      purposes of saving life in an emergency anyone can administer adrenaline 1 in
      1000 intramuscular injection. No prescribing qualification or PGD is required.

Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 10 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
11.0     DEFIBRILLATION

•      Defibrillation is an intervention which has been shown unequivocally to
       improve long-term survival in the treatment of cardiac arrest. [Ref
       Cardiopulmonary Resuscitation, Standards for Clinical Practice and Training
       Resuscitation Council [UK]; October 2004].
•      Defibrillators must only be operated by persons specifically trained in their
       use, who are based on hospital or PCT premises.
•      B&NES NHS has predominantly Automated External Defibrillators. The
       advisory only defibrillator has no manual facility. The whole process is
       automated. The machine interprets the cardiac rhythm, decides whether a DC
       shock is required, selects the amount of energy and charges the machine.
       The operator must ensure the environment is safe to defibrillate and deliver
       the shock by pressing the button on the machine. The process is aided by
       voice prompts from the defibrillator itself.
•      One community hospital has a manual / shock advisory defibrillator. This
       offers the operator two modes: to use the advisory capacity detailed as
       above. The alternative method is where the operator is entirely responsible
       for the safe and appropriate delivery of a shock. The user must interpret the
       arrest rhythm, select the required energy, charge the machine and deliver the
       shock safely.

12.0     DO NOT ATTEMPT RESUSCITATION (DNAR)

NHS B&NES developed this DNAR procedure which fully complies with the
guidance issued by the BMA/RCN/Resuscitation Council (UK) (2005) and the
recommended standards issued in the Joint Statement from the Royal College of
Anaesthetists, the Royal College of Physicians, the Intensive Care Society and
the Resuscitation Council (UK) standards for clinical practice and training that
state:

•   It is essential to identify (a) patients for whom cardiopulmonary arrest is an
    anticipated terminal event and in whom cardiopulmonary resuscitation (CPR)
    is inappropriate; and (b) patients who do not want to be treated with CPR.
•   All institutions should ensure that there is a clear and explicit resuscitation plan
    for all patients. For some patients this will involve a DNAR decision
•   Where there is no resuscitation plan and the wishes of the patient are
    unknown, resuscitation should be initiated if cardiopulmonary arrest occurs.
    However, a decision not to attempt resuscitation may be appropriate when; the
    patient’s condition indicates that CPR is unlikely to be successful, or CPR is
    not in accord with an applicable Advanced Decision, or successful CPR is
    likely to be followed by a length and quality of life that is not in the best
    interests of the patient

The overall responsibility for decision about DNAR orders rests with the doctor in
charge of the patient’s care. If a patient arrests in the evening, overnight or at
weekends when there is no doctor on site, if a DNAR order is not present, staff
must resuscitate until the paramedics arrive.


Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 11 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
Adherence to the Mental Capacity Act (2005) which came into force on 1st April
2007 is a legal requirement and must always be referred to when considering
DNAR orders and Advanced Decisions. For the vast majority of patients receiving
care in community hospitals or the community the likelihood of cardiopulmonary
arrest is small and no advance decision is made.

Where a DNAR decision has not been recorded in the medical and nursing notes
and the precise wishes of the patient are unknown, cardiopulmonary resuscitation
(CPR) must be initiated by the clinical team if cardiac or respiratory arrest occurs
and it is in the patient’s best interest.

There are occasions when it is not in a patient’s best interest to initiate CPR e.g.
terminal care. However, where a DNAR decision has not been recorded and the
patient is not competent, decisions about whether to provide treatment must be
taken in a way that reflects their best interests, an assessment of which includes
their clinical interests, plus any current and previously expressed wishes and
preferences. Where no such information is available, decisions must be
consistent with the patient’s interests and rights. If possible, it is also important to
discuss resuscitation with those close to the patient, and the clinical team.

12.1 When to consider a – Do Not Attempt Resuscitation (DNAR) - order

A do not attempt resuscitation order records a prior decision that in the event of an
individual patient suffering a cardiac and or respiratory arrest it would not be
appropriate for CPR to be undertaken.

Circumstances where CPR may not be appropriate:

a) Where the patient’s condition indicates that effective CPR is unlikely to be
   successful e.g. community staff make a decision not to resuscitate if they
   arrive at a patient’s home, and in their professional judgement the patient
   would not be revived if CPR commenced.
b) Where successful CPR is likely to be followed by a length and quality of life,
   which would not be acceptable to the patient.
c) Where CPR is not in accord with the recorded, sustained wishes of the patient
   who is mentally competent. [refer to the Mental Capacity Act]
d) Where CPR is not in accordance with a valid applicable advance directive
   (anticipatory refusal or living will). A patient’s informed and competently made
   refusal, which relates to circumstances, which have arisen, is legally binding
   upon doctors.

In these instances a DNAR order may be made. An illustration of where a do not
resuscitate order could be considered is a patient suffering from primary cancer
with secondary metastases who has a palliative diagnosis from the GP. Other
palliative care cases including Chronic Obstructive Pulmonary Disease and Motor
Neurone Disease could also be considered.

Where a DNAR order has not been made and the express wishes of the patient
are unknown, resuscitation should be initiated if cardiac or pulmonary arrest
occurs.


Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 12 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
12.2   Making and Management of a Do Not Attempt Resuscitation order
12.2.1 Responsibilities
The overall responsibility for a DNAR order rests with the General Practitioner or
Consultant (responsible doctor) in charge of the patient’s care. The decision must
be made after consultation and consideration of all aspects of the patient’s
condition.

Discussions of CPR with all patients would be inappropriate, causing unnecessary
distress to some. However if the likely outcome of a CPR intervention is uncertain
for example, with patients who are at risk of cardiac or respiratory failure or have a
terminal illness, the responsible Doctor concerned must undertake sensitive
exploration of their wishes regarding resuscitation, where this is possible, and
document them.

Any discussions with patients, any anticipatory decisions, and any circumstances
in which it is not possible or appropriate to discuss CPR with a patient must be
documented, signed and dated, in the patient’s record.

12.2.2 Consultation and consideration when reaching a decision

Issues that need to be considered when reaching a decision on whether to
commence resuscitation:
• The patient’s known or ascertainable wishes
• Asking the patient’s relatives, carers, and where applicable, advocate to
   express a view but this must be from the perspective of the patient, not their
   own perspective
• The clinical perspectives of other members of the medical and nursing team
• If required, an interpreter should be present to help the patient and relatives
   understand the circumstances and ensure that his or her views are expressed
   coherently.

Each patient must be seen as an individual case, and as such any religious and
cultural beliefs must be respected. Those to be consulted and the method of
consultation must depend on the individual case.

Competent young people are entitled to give consent to medical treatment. Their
views must be taken into consideration in decisions about attempting CPR.
Where they lack competence it is generally the person with parental responsibility
who makes decisions on their behalf. If a DNAR order is being considered for a
young person, that person’s competence and the legal position must be
addressed. Legal advice may be required. Contact the Director or the Director on
call [out of hours] for access to PCT Legal Services.

A DNAR order based on the quality of life of the patient must particularly take into
account the views of the patient and those close to the patient i.e. the relatives
and carers. The relatives and carers must only be asked to express a view from
the perspective of the patient, not their own perspective. The final decision must
be based on the patient's current state of health and the likely outcome of any
CPR attempt; it must not be determined by factors such as pre- existing disability.

Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 13 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
The above process means there is both a multidisciplinary approach and it also
ensures that patients’ rights are central to the decision making on resuscitation.

A DNAR order applies solely to CPR. It must be made clear to the patient,
relatives and all concerned that all other treatment and care which are
appropriate for the patient are not prohibited and will not be influenced by a
do not resuscitate order.

12.2.3 Documentation and communication of the Do Not Attempt
      Resuscitation order
Documentation and communication of the Do Not Resuscitate orders are
essential.
• A review of the patient’s status by the responsible doctor for a DNAR order can
   be instigated by any member of the multi-disciplinary team, patient or the
   appropriate relative, carer or advocate weekly.
• To communicate the DNAR order, a blue order sheet (appendix F) must be
   completed, stating both the clinical justification and stating who was consulted
   in making the decision.
• The DNAR order sheet will be completed and filed in the patients nursing
   notes.
• The responsible doctor must ensure that the nurse caseload holder or referring
   health professional is aware of this decision.
• The case-load holder or referring health professional for that patient is obliged
   to ensure that all nursing staff including bank and agency staff are aware of a
   DNAR order.
• Other health care professionals involved in the patient’s care must be informed
   of the resuscitation status of the patients by the appropriate nursing staff.
   These health professionals must then check the nursing notes to confirm the
   status of the patient.
• Where possible and appropriate the responsible doctor must ensure any
   decision to make a DNAR order is communicated to the patient and relative(s)
   or carer(s).
• The responsible doctor must set a date for REVIEW of the DNAR order
   appropriate to the patient’s circumstances or at any time if there is a change in
   the patient’s condition or wishes.
• When a patient is transferred from one clinical setting to another with a DNAR
   order, the responsible doctor must review the order.
• When a DNAR order is cancelled by the responsible doctor this should be
   stated clearly in the clinical notes and a single line drawn across the do not
   resuscitate order sheet signed and dated by the responsible doctor.
• The reversal of the DNAR order must again be made after appropriate
   consultation and consideration of all aspects of the patient condition.

12.2.4 Legal considerations

By law, patients and where appropriate their relatives and carers have the right,
wherever possible, to be involved in resuscitation decisions, as they do in other
decisions concerning their treatment and care. Doctors, as with all decision-

Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 14 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
making, have a duty to act in accordance with a responsible and appropriate body
of professional opinion.

This policy adheres to the guidelines given by the statement entitled ‘Decisions
relating to Cardiopulmonary Resuscitation (CPR)’ by the Resuscitation Council
(UK), the British Medical Association and the Royal College of Nursing in March
2001. These guidelines are considered best practice for a resuscitation policy.


13.0   PROCESS FOR MONITORING COMPLIANCE WITH AND THE
       EFFECTIVENESS OF THIS POLICY
All events to which a patient has to be resuscitated must be audited (DoH HSC
2000/028):
• An adverse event form to be completed in the event of CPR, with special
    relevance if CPR unsuccessful, in each clinical area.
• All critical events will be reported to the Clinical Risk Group
• An annual report of resuscitation practice and outcome will be produced and
    go to the Clinical Standards Group. A named Resuscitation Lead for the PCT
    to complete this report.

The Clinical Risk Group will:
• Lead on the monitoring of the minimum (Level 1) requirements within the
   current NHSLA Risk Management Standards
• Review the educational and clinical audit outcomes produced from the Training
   Department data.
• Feed back review findings to the Clinical Standards Group.

14.0   PROCESS FOR REVIEWING, APPROVING AND ARCHIVING THIS
       DOCUMENT
This document will be reviewed after two years or whenever national policy or
Guidelines change, whichever is the sooner. Archiving of this document must be
conducted in accordance with the organisation’s electronic archiving procedure.

15.0   DISSEMINATION, IMPLEMENTATION AND ACCESS TO THIS
       DOCUMENT
This policy must be implemented and disseminated throughout the organisation
immediately following ratification, and will be published on the organisation’s
intranet site. Access to this document is open to all.

16.0   REFERENCES

Human Rights Act, [1998], HMSO

Mental Capacity Act 2007 Department of Health

NHS Executive. Resuscitation Policy (HSC 2000/028). London: Department of Health,
September 2000.


Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 15 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
A Joint Statement from the British Medical Association, the Resuscitation Council (UK)
and the Royal College of Nursing, Decisions Relating to Cardiopulmonary Resuscitation.
London: BMA Ethics Department, October 2007. Full Guideline available on BMA’s
website at www.bma.org.uk/cpr.

National Health Service Litigation Authority (2007) NHSLA Risk Management
Resuscitation Document

Resuscitation Policy, Health Services Circular (HSC) 2000/028. London.
Department of Health.

Resuscitation Council (UK) (2001) Decisions relating to Cardiopulmonary
Resuscitation. A Joint Statement from the British Medical Association, the
Resuscitation Council (UK) and the Royal College of Nursing. Online at:
http://www.resus.org.uk/pages/dnar.htm

Resuscitation Council (UK) (2004) Cardiopulmonary Resuscitation – Standards for
Clinical Practice and Training. A Joint Statement from the Royal College of
Anaesthetists, the Royal College of Physicians of London, the Intensive Care
Society and the Resuscitation Council (UK). Online at:
http://www.resus.org.uk/pages/guide.htm

Resuscitation Council (UK) (2005) Resuscitation Guidelines 2005. Online at:
http://www.resus.org.uk/pages/guide.htm

Resuscitation Council [UK]] [2008]. Emergency Treatment of Anaphylactic
Reactions, Guidelines for Healthcare Providers. Online at:
http://www.resus.org.uk/pages/reaction/pdf

Resuscitation Council (UK) (2001) Guidance for Safer Handling during
Resuscitation in Hospital.

Note: the DNAR section of this policy has been adapted from the
Riverside Community Trust Resuscitation Policy


17.0 PCT RELATED POLICIES

The following Trust policies / procedures may also need to be read in conjunction with
this document:
•   Manual Handling
•   Universal Precautions / standard precaution policy
•   Blood Borne Virus Policy
•   Adverse Event Reporting Policy and Procedure
•   Medical Devices Policy




Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 16 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
                                                                              APPENDIX A
                                   Resuscitation Flowchart ADULTS

         •    Assess for DANGER. Is it safe to approach?


         •    Check for RESPONSE. Shout, shake gently, use painful stimuli


         •    Shout for HELP from colleague, activate panic alarm


         •    Check AIRWAY. Head tilt chin lift, look inside mouth for any obstruction

         •    Is the patient BREATHING NORMALLY? Look, listen and feel for NO MORE
              than 10 seconds.


                          NO                                               YES


•    Send Colleague to dial 9/999 for                       •   ASSESS patient
     an ambulance and then to collect
     the AED with crash bag and return                      •   Place in the RECOVERY
     to you and casualty ASAP                                   POSITION

•    If you are alone go and dial 9/999                     •   Summon further HELP
     for an ambulance and return to the
     casualty ASAP and start CPR.                           •   Assess DRABC

                                                            •   WARM and REASSURE

                                                            •   Wait with casualty



    Commence Resuscitation
         - 30 Compressions
              - 2 Breaths
Do NOT STOP unless
                                                           As soon as AED is available,
     o       Casualty starts breathing normally            switch on and follow voice prompts
     o       Qualified help takes over
     o       You become too exhausted


If another rescuer is present, they should take
over CPR every two minutes to prevent fatigue




    Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
    Page 17 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
                                                                               APPENDIX B

                         Resuscitation Flowchart – Paediatrics

   •     Assess for DANGER. Is it safe to approach?


   •     Check for RESPONSE. Shout and check for response.
         Infant = flick sole of foot. Child = tap shoulder

   •     Shout for HELP from colleague, activate panic alarm


   •     Check AIRWAY. Head tilt chin lift, look inside mouth for any obstruction

   •     Is the patient BREATHING NORMALLY? Look, listen and feel for NO MORE than 10
         seconds.


                    NO                                                    YES


                                                               •   ASSESS casualty
    • IF ACCOMPANIED send
                                                               •   Place in the RECOVERY
      colleague to dial 9/999 for an
                                                                   POSITION
      ambulance and then to collect
      the resuscitation grab bag and                           •   Summon further HELP
      return to you and casualty                               •   Assess DRABC
      ASAP.                                                    •   WARM and REASSURE
                                                               •   Wait with casualty
       • If you are ALONE, give 1
         minute of resuscitation.
         Immediately give 5 breaths.




   Commence Resuscitation
          - 30 Compressions
               - 2 Breaths
Do NOT STOP unless

   o     Casualty starts breathing normally

   o     Qualified help takes over

   o     You become too exhausted

If another rescuer is present, they
should take over CPR every two
minutes to prevent fatigue



  Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
  Page 18 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
                                                                              APPENDIX C
                    Resuscitation Flowchart
  Healthcare Professionals with a Duty to Respond – Flowchart


   •     Assess for DANGER. Is it safe to approach?


   •     Check for RESPONSE. Shout and check for response.
         Infant = flick sole of foot. Child = tap shoulder

   •     Shout for HELP from colleague, activate panic alarm


   •     Check AIRWAY. Head tilt chin lift, look inside mouth for any obstruction

   •     Is the patient BREATHING NORMALLY? Look, listen and feel for NO MORE than 10
         seconds.


                   NO                                                       YES


    • IF ACCOMPANIED send
                                                               •   ASSESS casualty
      colleague to dial 9/999 for an
                                                               •   Place in the RECOVERY
      ambulance and then to collect
                                                                   POSITION
      the resuscitation grab bag and
      return to you and casualty                               •   Summon further HELP
      ASAP.                                                    •   Assess DRABC
                                                               •   WARM and REASSURE
       • If you are ALONE, give 1                              •   Wait with casualty
         minute of resuscitation.
         Immediately give 5 breaths.



                                                                    YES
        Assess for signs of life                           Commence Rescue Breaths
   •     Look for normal breathing                             20 per minute
   •     Obvious movement
   •     Cough / gag responses
   •     Check pulse (if trained)

                                                          Do NOT STOP unless
                    NO
                   NO                                          o   Casualty starts breathing
                                                                   normally
        Commence Resuscitation
                                                               o   Qualified help takes over
            15 compressions
               2 Breaths                                       o   You become too exhausted

                                                          If another rescuer is present, they
                                                          should take over CPR every two
                                                          minutes to prevent fatigue

Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 19 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
                                                                          APPENDIX D

        Equipment and Resuscitation Drugs (and Accessories)
All in-patient areas are required to hold an approved list of equipment and
resuscitation drugs. These must be checked daily and logged to ensure that
equipment is always fit for purpose.

ALL staff (including bank, agency, students etc.) must be made aware of the
location and method of accessing resuscitation equipment. This must be covered
as part of staff initial health and safety induction/orientation.

All resuscitation equipment and resuscitation drugs on the approved list will be
checked daily. This will be recorded. Ideally, this responsibility will be delegated
to an appropriate person(s) as per local protocols.

All resuscitation equipment and resuscitation drugs must be maintained in a clean
state and stored appropriately and be ready for immediate use.

Where required, emergency drugs will be stored for use in each area and checked
by pharmacy to ensure valid dates and contents.

Within the ward and other in-patient areas, AEDs will be located in such places so
as to ensure they are accessible within 3 minutes (Resuscitation Council 2005).

When locating AEDs, consideration must be given to ease of access and the
method by which this is achieved. This information must be included in local
procedures and communicated to ALL staff working within ward and other in-
patient areas environment, whether permanent or not.

Following a cardiac arrest, all used equipment must be replaced within 12 hours.

Each area holding emergency resuscitation equipment will ensure that the
following documents/information are available and located appropriately:

    •   Resuscitation flowchart
    •   Daily checklists
    •   Trust resuscitation policy
    •   Procedures for summoning help
    •   AED located here sticker

Recommended List of Resuscitation

Airway Equipment

•   Pocket mask with oxygen port (should be widely available in all clinical areas)
•   Self-inflating resuscitation bag with oxygen reservoir and tubing (ideally, the
    resuscitation bag should be single use – if not, it should be equipped with a
    suitable filter)
•   Clear face masks – sizes 3, 4 & 5
Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 20 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
•   Oropharyngeal airways – sizes 2, 3 & 4
•   Portable suction equipment
•   Yankauer suckers
•   Lubricating jelly
•   Scissors
•   Selection of syringes
•   Oxygen mask with reservoir (non-rebreathing bag)
•   Oxygen cylinders
•   Cylinder key

Circulation Equipment

•   Defibrillator (shock advisory module]
•   ECG electrodes
•   Defibrillation pads pr self-adhesive defibrillator pads (preferred)
•   Selection of intravenous cannulae
•   Selection of syringes and needles
•   Cannula fixing dressings and tapes
•   Intravenous infusion sets
•   0.9% sodium chloride – 1000mL x 2
•   Glucose 5% 500 mls x 1
•   Tourniquet

Drugs

Immediately available pre-filled syringes

•   Adrenaline (epinephrine) 1 mg in 10ml (1:10,000)      6 x 10mls
•   Atropine 3 mg in 30ml                                 1 x 30mls
•   Calcium Chloride 10%                                  1 x 10mls
•   Amiodarone 300mg in 10ml                              1 x 10mls
•   Magnesium Sulphate 10% [8mmol in 20ml]                2 x 10mls

Additional Items

•   Gloves/goggles/aprons
•   Audit forms
•   Sharps container and clinical waste bag
•   Large scissors
•   Alcohol wipes
•   Blood sample bottles
•   A sliding sheet or similar device should be available for safer handling


Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 21 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
Documentation

The following documentation must be available for use/reference where
defibrillators have been placed. Departments may consider creating a stand-
alone ‘resuscitation folder.

•   Resuscitation flowchart (with AED and elsewhere as required)
•   Defibrillator daily checklists
•   Resuscitation policy
•   AED sticker (attached externally to the permanent facility in which the AED is
    kept)
•   Help form (detailing who can answer AED related queried with workplace)
•   Approved list of contents for AEDs

Further information

The following Trust policies/procedures may also need to be read in conjunction
with this document:

•   Do not attempt resuscitation (DNAR) policy
•   Manual handling
•   Universal precautions/standard precautions policy
•   Blood borne virus policy
•   Serious adverse incident policy
•   Medical devices policy

Anaphylaxis boxes on the ward

Standard Drugs for use in Anaphylaxis box:

    •   Adrenaline 1 in 1000          2 x 1ml
    •   Chlorphenamine 10mg in 1ml 5 x 1ml
    •   Hydrocortisone sodium succinate 100mg with dilutent 2 x 100mg
    •   Salbutamol nebules 2.5mg in 2.5ml                    5 x 2.5ml
    •   Sodium chloride 0.9%                                 2 x 5ml
    •   Syringes, needles and sterets

Community Staff

    •   All PCT employed staff on the community who give injections carry
        adrenaline 1 in 1000 intramuscular injection and will call 999 if it has to be
        used.




Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 22 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
                                                                          APPENDIX E

                       Equipment to be Checked Weekly
                   ADULT RESUSCITATION EQUIPMENT CHECKLIST

                              NAME         NAME        NAME         NAME         NAME

                            Signature    Signature   Signature    Signature    Signature

Date Checked

Automated Defibrillator

Disposable Razor

Disposable Wipes

Defibrillator Pads (x 2)

Pocket Mask with oxygen
inlet

Oro-pharyngeal Airways
size 2

Oro-pharyngeal Airways
size 3

Oro-pharyngeal Airways
size 4

Hand held suction device

Tough cut scissors

Resuscitation flow chart

No re-breathing 02 mask
and tubing

Gloves (latex free)

Bolt Cutters

Full Oxygen Cylinder
(portable)

Spare battery for AED (if
applicable)

Comments




Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 23 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
                                                                             Appendix F




Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 24 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
                                                                                 Appendix G

                         Do Not Attempt Resuscitation Order Sheet
                           To be completed by the responsible doctor


                                          Patient Details

Name
Address


Date of Birth


Assessment requested by:

Clinical Justification




          Discussion with                      Name                    Date            Time
Patient                    Yes/No
Relatives                  Yes/No
Carers/Advocates/ Yes/No
Other
Nursing Staff         Yes/No
Other Professionals        Yes/No

Further Comments: (To include if patient has made an Advance Directive or verbal request
not to be resuscitated)




NB: The RESPONSIBLE DOCTOR should set a date for REVIEW of the Do Not Resuscitate
order appropriate to the patient’s circumstances or at any time if there is a change in the
patient’s condition or wishes.
When a Do not Resuscitate order is cancelled by the responsible doctor, that person will
boldly score with a single line across this sheet and sign and date.

A decision has been reached for a ‘Do Not Resuscitate Status’ for this patient

Date:                                  G.P/Consultant Signature:
Comment: (Next Review Date)




Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 25 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011
Review/Cancellation of Do Not Resuscitate Status

Date:                               G.P/Consultant Signature:
Comment: (Next Review Date)




Review/Cancellation of Do Not Resuscitate Status

Date:                              G.P/Consultant Signature:
Comment: (Next Review Date)



Review/Cancellation of Do Not Resuscitate Status

Date:                              G.P/Consultant Signature:
Comment: (Next Review Date)




Review/Cancellation of Do Not Resuscitate Status

Date:                               G.P/Consultant Signature:
Comment: (Next Review Date)



NB: The RESPONSIBLE DOCTOR should set a date for REVIEW of the Do Not Resuscitate
order appropriate to the patient’s circumstances or at any time if there is a change in the
patient’s condition or wishes.
When a Do not Resuscitate order is cancelled by the responsible doctor, that person will
boldly score with a single line across this sheet and sign and date.




Title:  Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Policy
Page 26 of 26 Version: 2    Date of Issue: October 2009   Date of Review: September 2011

				
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