Do Not Attempt Resuscitation _DNAR_ Policy by sdfgsg234


									                     Harrow Primary Care Trust

Do Not Attempt Resuscitation (DNAR) Policy

 Version:                        V02
 Name of originator/author:      Beverly Everist, Head of Provider
 Responsible Director:           Jon Ota, Director of Services and
 Date ratified:                  March 2009
 Ratified by:                    Quality & Governance Committee
 Pre-approval committee:         n/a
 Superseded policy (if           Do Not Attempt Resuscitation Policy
 applicable):                    July 2005
 Next review date:               March 2011
 Target audience:                All Clinical Staff, Trust-wide
 Date published to Trust Internet March 2009
Harrow PCT


1    KEY WORDS                                                                          3
2    ASSOCIATED TRUST DOCUMENTS                                                         3
3    INTRODUCTION                                                                       3
     3.1 Purpose                                                                        3
     3.2 Scope                                                                          3
     3.3 Definition                                                                     4
4    DUTIES                                                                             4
     4.1 Consultant / GP’s Responsibilities                                             4
     4.2 All Staff                                                                      5
5    PROCEDURE/COURSE OF ACTION REQUIRED                                                5
     5.1 In emergencies                                                                 5
     5.2 Advance Decision Making                                                        5
     5.3 Care Setting                                                                   6
          5.3.1 Inpatients                                                              6
          5.3.2 Patient’s Home                                                          6
          5.3.3 Clinic Sites                                                            6
     5.4 Management of Do Not Attempt Resuscitation Orders                              6
         5.4.1 Consultation and consideration when reaching a decision                  6
         5.4.2 When to consider a Do Not Attempt Resuscitation Order                    7
     5.5 Documentation and Communication of the Do Not Attempt
         Resuscitation Order                                                            8
6    IMPLEMENTATION PLAN                                                                8
     6.1 Consultation                                                                   8
     6.2 Ratification                                                                   8
     6.3 Dissemination                                                                  9
     6.4 Training/Awareness                                                             9
     6.5 Audit                                                                          9
     6.6 Information for Patients/Service Users                                         9
7    REFERENCES                                                                         9
8    VERSION HISTORY TABLE                                                         10

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1       KEY WORDS
Resuscitation; cardiopulmonary resuscitation; CPR; Do Not Attempt Resuscitation;
DNAR; Basic Life Support; BLS; respiratory arrest; cardiac arrest; Advance Decision.

This document should be read in conjunction with the following Trust documents:

      • Consent Policy
      • Mental Capacity Act 2005
      • Resuscitation Policy.

This document describes the Do Not Attempt Resuscitation (DNAR) Policy for Harrow
Primary Care Trust (PCT). It is Harrow PCT policy that Cardiopulmonary Resuscitation
(CPR) or Basic Life Support (BLS) should be attempted on every person who suffers a
cardiac and/or respiratory arrest in any of its premises, subject to the provision below.

In most instances resuscitation policies can operate on a Trust-wide basis, the default
position being that, in the event of a cardiopulmonary arrest, there is a presumption in
favour of attempted cardiopulmonary resuscitation (CPR). This means that, in order for
CPR not to be attempted, a specific order to this effect must be documented in the
notes of the individual concerned. This is known as a Do Not Resuscitate order (DNR)
or, more commonly now, DNAR (Do Not Attempt Resuscitation). It is seen as
recognition that the primary goals of medicine, which are to maximise benefit and
minimise harm, are not served by prolongation of the patient’s life at all costs.

3.1     Purpose

The purpose of this policy document is:

•     To inform staff of the Trust policy for Do Not Attempt Resuscitation (DNAR);
•     To help to ensure all staff understand and implement the Do Not Attempt
      Resuscitation (DNAR) Policy;
•     To provide for appropriate supervision arrangements to review resuscitation
      decisions with the patient/relatives/carers and staff;
•     To ensure patients’ rights are central to decision-making on resuscitation;
•     To provide a baseline of good practice for clinical audit.

3.2     Scope

This policy is applicable to all members of staff who deal with patients.

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3.3     Definition

Anaphylaxis:- A severe, life threatening, generalized or systemic hypersensitivity
reaction. (Resuscitation Council UK).

Cardiac Arrest:- A cardiac arrest is a sudden and complete loss of mechanical cardiac
function ascertained by an absence of detectable signs of life and if trained to detect it
an absence of palpable pulsation in a major artery. Cardiac arrest may be due to
ventricular fibrillation, pulseless ventricular tachycardia, asystole, or electromechanical
dissociation. Within hospitals a high percentage of cardiac arrests will be preceded by
detectable clinical deterioration.

Cardiopulmonary resuscitation (CPR) or Basic Life Support (BLS):- can be defined
as any immediate emergency treatment aimed at restoring spontaneous circulation and
breathing to the patient or in special circumstances staff or member of the public.

CPR can be attempted on any individual where cardiac and respiratory function ceases.
As cardiac and respiratory failure is an inevitable part of dying, it is important to identify
patients for whom cardiopulmonary arrest represents a terminal event in their illness
and in whom CPR is inappropriate.

Respiratory Arrest:- Respiratory arrest can be divided into two major components both
of which require urgent management. It is very unusual for either to occur without being
preceded by detectable clinical deterioration.
    • Absolute: A sudden and complete cessation of breathing.
    • Functional: Ventilatory or Respiratory function so reduced from the normal that
       oxygenation and or removal of carbon dioxide is reduced to a level that threatens

4       DUTIES
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.

4.1     Consultant / GP’s Responsibilities

After appropriate consultation and consideration of all aspects of a patient’s condition
the Consultant / GP must:-

•     Hold the overall responsibility for the authorisation of DNAR orders.
•     Should undertake sensitive exploration of the patient’s wishes regarding
      resuscitation and document these discussions within the patient’s records.
•     To ensure that a date is set for the review of DNAR’s, which is appropriate for the
      patient’s condition or wishes.
•     To ensure that all DNARs/Advanced Decisions status, reviews or cancellations are
      communicated to the multi-disciplinary team.
•     When a patient is transferred from one clinical setting to another with a DNAR or
      known Advanced Decision, the Consultant/GP (responsible doctor) must review the

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4.2     All Staff

• Ensure that the directions set out in this policy are adhered to and implemented in
• Establish, where appropriate, decisions from patients and carers existence of
  Advanced Decisions.
• To actively clarify/confirm a patient’s DNAR or Advanced Decision status through
  routine sensitive discussions with patients and record these discussions within
  patient records.
• Any member of the multi-disciplinary team can instigate a review of a patient’s
  status, but all reviews are the responsibility of Consultants/GPs.

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-making,
have a duty to act in accordance with a responsible and appropriate body of
professional opinion.

Patients’ rights under the Human Rights Act must be taken into account in decision
making. The Mental Capacity Act 2005 provides a statutory framework to empower and
protect vulnerable people who are not able to make their own decisions. It makes it
clear who can take decisions, in which situations, and how they should go about this. It
enables people to plan ahead for a time when they may lose capacity. Guidance set out
in the Act should be considered when implementing this policy.

5.1     In emergencies

If no advance decision has been made or is known, CPR should be attempted unless:

      • the patient has refused CPR;
      • the patient is clearly in the terminal phase of illness;
      • or the burdens of the treatment outweigh the benefits.

5.2     Advance Decision Making

•     Competent patients should be involved in discussions about attempting CPR unless
      they indicate that they do not want to be.
•     Staff undertaking discussions around advanced decisions should seek advice from
      Corporate Governance.

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5.3     Care Setting

5.3.1 Inpatients

DNAR Policy will apply to all staff within Inpatient Units. Consultants responsible for
patients will record DNARs within patient records. All staff should be aware of the
patient’s DNAR status through routine communication mechanisms/nursing
reports/hand over.

5.3.2 Patient’s Home

•     DNAR Policy will apply to all staff within patients’ homes. The GP, in consultation
      with other medical colleagues, where appropriate is responsible for recording DNAR
      notices and liaising with the wider multi-professional team, i.e. District Nurses and
      the London Ambulance Service.
•     All staff should actively clarify/confirm the patient’s DNAR or Advanced Decision
      status through routine sensitive discussions with the patient and their
      relatives/carers. This should be communicated through normal mechanisms/nursing
      reports/hand over and ensure that it is recorded in the appropriate records.
•     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.

5.3.3 Clinic Sites

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.

5.4     Management of Do Not Attempt Resuscitation Orders

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 should be
made after consultation and consideration of all aspects of the patient’s condition.

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 should undertake sensitive exploration of their wishes
regarding resuscitation, where this is possible.

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

5.4.1 Consultation and consideration when reaching a decision

Issues that need to be considered are:

•     The patient’s known or ascertainable wishes.
•     A DNAR order based on the quality of life of the patient should particularly take into
      account the views of the patient and those close to the patient i.e. the relatives,
      carers and where applicable an advocate. The relatives and carers should only be

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    asked to express a view from the perspective of the patient, not their own
    perspective. The final decision should be based on the patient's current state of
    health and the likely outcome of any CPR attempt; it should not be determined by
    factors such as pre-existing disability.
•   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
•   Each patient should be seen as an individual case, and as such any religious and
    cultural beliefs should 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.

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 should 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 DNAR order.

5.4.2 When to consider a Do Not Attempt Resuscitation 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 resuscitation to be undertaken.

Circumstances where CPR may not be appropriate are:

•   Where the patient’s condition indicates that effective CPR is unlikely to be
•   Where successful CPR is likely to be followed by a length and quality of life, which
    would not be acceptable to the patient;
•   Where CPR is not in accord with the recorded, sustained wishes of the patient who
    is mentally competent;
•   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
Attempt Resuscitation 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, Heart Failure
and Motor Neurone Disease could also be considered.

2009-Mar_Do_Not_Attempt_Resuscitation_V02_rat.doc                               Page 7 of 12
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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

5.5     Documentation and Communication of the Do Not Attempt Resuscitation

•     Documentation and communication of the DNAR 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.
•     To record a DNAR order utilise the DNAR PCT Proforma (Appendix A), 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 patient’s healthcare
•     The responsible doctor should ensure that the nurse caseload holder/key worker 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 agency staff are aware of a DNAR order.
•     Other healthcare professionals involved in the patient’s care should be informed of
      the resuscitation status of the patient by the appropriate nursing staff. These health
      professionals should then check the healthcare record to confirm the status of the
•     Where possible and appropriate the responsible doctor should ensure any decision
      to make a DNAR order is communicated to the patient and relative(s) or carer(s).
•     The responsible doctor should 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/healthcare record and a single line across the DNAR
      order sheet signed and dated by the responsible doctor.
•     Cancelled DNAR orders should be made after appropriate consultation and
      consideration of all aspects of the patient’s condition.

6.1     Consultation

Quality and Governance Committee.

6.2     Ratification

Ratification of this policy will be obtained by the Quality & Governance Committee
following approval from the Director of Services & Nursing, Director of Public Health or
Medical Director.

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6.3     Dissemination

Once this policy has been ratified, the Integrated Governance Team will publish the
policy on the PCT internet site and will also email all staff the policy synopsis to inform
staff of the new policy and its location on the Trust internet site.

All managers and staff have responsibility for cascading this information to their staff
and ensuring that any changes to the policy are communicated to staff.

6.4     Training/Awareness

Basic Life Support training is specified in the Risk Management Training Policy.

6.5     Audit

Adherence to this policy will be audited yearly within the Trust. The audit process will
involve all relevant health professionals to help identify areas where improvement is

Any attempt at CPR must be competent and in accordance with established clinical
guidelines. Performance of CPR and experience with DNAR orders should be the
subject of clinical audit. The National Institute for Clinical Excellence provides
information and resources for clinical audit.

Review of the audits and incidents of DNAR implemented will be monitored by the
Clinical Governance Team.

6.6     Information for Patients/Service Users

Written information about resuscitation should be included in the general literature
provided to patients. Such information should be readily available to all patients and to
people close to the patient including relatives and partners. Its purpose is to de-mystify
the process by which decisions are made and to explain what facilities are available.
Patients should be encouraged to see such information as a routine part of advance
care planning to cover all contingencies rather than an intimation of a particular risk to
themselves. Information should reassure patients of their part in decision making and
should make clear that for most patients the question may not arise. Nevertheless, all
patients and those close to them can ask for time to be set aside to discuss the issues if
they feel they will be relevant to them. Local policies may include mention of how such
non-urgent discussions can best be accommodated, and where people can go for
further advice and information.

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

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    • A Joint Statement from the British Medical Association, Resuscitation Council
      (UK) and the Royal College of Nursing, Decisions Relating to Cardiopulmonary
      Resuscitation. London: BMA Ethics Department, March 2001. Full Guideline
      available on BMA’s website at
    • Human Rights Act 1998
    • Decisions Relating to Cardiopulmonary Resuscitation (2003) Joint statement
      from the Royal College of Nursing, British Medical Association, Age Cancer, the
      Resuscitation Council (UK), July
    • Booty, F. (2006) Guidance for resuscitation in establishments other than acute
      hospitals. Healthcare Commission publication, September
    • Hilberman, M. Kutner, J. Parsons, D. and Murphy, D.J. (1987) Marginally
      effective medical care: ethical analysis of issues in cardiopulmonary resuscitation
      (CPR). Journal of Medical Ethics 23:
    • Zoch, T.W. Desbiens, N.A. DeStefano, F. Layde, P.M. (2000) Short and long-
      term survical after cardiopulmonary resuscitation. Archives of Internal Medicine;
      160: 1969 – 1973
    • Beauchamp, T.L. Childress, J.F. (1994) Principles of Biomedical Ethics, 4th Edn.
      Oxford University Press
    • Joint Working Party between the National Council for Hospice and Specialist
      Palliative Care Services and the Ethics Committee of the Association for
      Palliative Medicine of Great Britain and Ireland. Ethical decision-making in
      palliative care: cardiopulmonary resuscitation (CPR) for people who are
      terminally ill. London: National Council for Palliative Care Services, August 1997


     2         February 2009          Beverly Everist   Compliance with NHS Litigation
                                                        Authority criteria

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                                        Affix patient label here
 A brief résumé of the reasons why the decision was made should prompt the written
 agreement e.g. In view of the irreversible and progressive nature of the patient’s illness, death
 is now seen as inevitable.

     In the event of a cardio-respiratory arrest a ‘Do Not Attempt Resuscitation’ decision has been made
     on the above patient.

     I have/have not discussed this decision with the patient/client or relatives/anybody else.

     This decision will be reviewed by the GP/Lead Consultant in accordance with the patient’s condition.

Signature                Name Printed              Status                    Date

--------------------     ---------------------     ---------------------     ---------------------

Review date:

Signature                Name Printed              Status                    Date

--------------------     --------------------      ---------------------     ---------------------

--------------------     ---------------------     ---------------------     ---------------------

--------------------     ---------------------     ---------------------     ---------------------

2009-Mar_Do_Not_Attempt_Resuscitation_V02_rat.doc                                              Page 11 of 12
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                   DNAR decisions should be reviewed regularly according to
                   the patient’s condition.
                   A DNAR decision should apply to the current hospital
                   admission only.
                   If the patient is readmitted, the resuscitation status of the
                   patient should be reviewed and new DNAR decisions
                   recorded in the notes is applicable.
                   All other treatment and care which are appropriate for the
                   patients are not precluded and should not be influenced by
                   a DNAR decision.

              NB: A DNAR decision applies solely to cardiopulmonary resuscitation

             (On discharge this form should be filed with the GP discharge summary).

2009-Mar_Do_Not_Attempt_Resuscitation_V02_rat.doc                             Page 12 of 12

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