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PARKSIDE HEALTH

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    Brent Teaching Primary Care Trust




    Policy for provision of facilities for
     Cardiopulmonary Resuscitation


       Date                                   January 2004
       Person responsible for policy / Lead   Director      of   Nursing,   Quality    &
                                              Clinical Governance
       Policy approved by Board/PEC on
       Policy Review Date                     September 2004
       Version No                             Revision History
       0.1                                    First draft


       Author / Lead                          Adapted             from        Parkside
                                              Resuscitation Policy




BRENT PCT POLICY FOR PROVISION OF FACILITIES FOR CARDIOPULMONARY
RESUSCITATION

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                                 CONTENTS




SECTION 1:     GENERAL INFORMATION                                       5

1.1   INTRODUCTION                                                       5

1.2   TERMS USED IN RESUSCITATION                                        6

1.3   THE SCOPE OF BRENT TEACHING PRIMARY CARE TRUST SERVICES            7

SECTION 2:     CARDIOPULMONARY RESUSCITATION                             9

2.1   CARDIOPULMONARY RESUSCITATION PATHWAYS (SEE APPENDIX 1)            9

2.4   DOCUMENTATION OF RESUSCITATION INCIDENTS (SEE APPENDIX 3)         10

SECTION 3:     DO NOT ATTEMPT RESUSCITATION (DNAR) ORDERS               11

3.1   WHAT ARE THEY?                                                    11

3.2   WHAT WILL BE PROVIDED IF A DNAR ORDER IS WRITTEN?                 11

3.3   WHAT WILL NOT BE PROVIDED IF A DNAR ORDER IS WRITTEN?             11

3.4   PRESUMPTION IN FAVOUR OF ATTEMPTING RESUSCITATION                 12

3.5   IN AN EMERGENCY                                                   12

3.6   WHEN IS IT APPROPRIATE TO CONSIDER MAKING A DNAR ORDER?           13

SECTION 4:     DECISIONS RELATING TO CARDIOPULMONARY RESUSCITATION 14

4.1   RESPONSIBILITY FOR RESUSCITATION DECISIONS                        15

4.2   TIMING OF RESUSCITATION DECISIONS                                 15

4.3   DOCUMENTATION OF RESUSCITATION DECISIONS                          16

4.4   REVIEW OF RESUSCITATION DECISIONS                                 16

SECTION 5:     AUDIT                                                    16



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SECTION 6:      REFERENCES                                                17

APPENDIX 1.1: CARDIOPULMONARY RESUSCITATION PATHWAYS                      18

APPENDIX 1.1: PATHWAY 1A:         BASIC LIFE SUPPORT (ADULT)              19

APPENDIX 1.1: PATHWAY 1B:          BASIC LIFE SUPPORT (PAEDIATRIC)        20

APPENDIX 1.1: PATHWAY 2A:         BASIC LIFE SUPPORT (ADULT)              21

APPENDIX 1.1: PATHWAY 2B:         BASIC LIFE SUPPORT (PAEDIATRIC)         22

APPENDIX 1.1: PATHWAY 3A:         ADVANCED LIFE SUPPORT (ADULT)           23

APPENDIX 1.1: PATHWAY 3B:         ADVANCED LIFE SUPPORT (PAEDIATRIC)      25

APPENDIX 2:     EQUIPMENT                                                 27

2.1: ORANGE BAGS FOR BASIC LIFE SUPPORT                                   27

APPENDIX 2.1:     ORANGE BAG MONTHLY CHECKLIST                            28

APPENDIX 2.2:     CARDIAC ARREST BOXES                                    29

APPENDIX 2.3:     RESUSCITATION TROLLEYS                                  30

STANDARD RESUSCITATION TROLLEY                                            30

APPENDIX 2.3:     RESUSCITATION TROLLEYS                                  31

MOBILE RESUSCITATION TROLLEY CONTENTS LIST                                31

APPENDIX 2.3:     MOBILE RESUSCITATION TROLLEY: ORANGE RUCKSACK
CONTENTS          32

RESUSCITATION TROLLEYS                                                    32

APPENDIX 3.1:     RECORD FOR BASIC LIFE SUPPORT RESUSCITATION             33

APPENDIX 3.2: RECORD FOR ADVANCED LIFE SUPPORT RESUSCITATION              34

APPENDIX 5:     FURTHER POINTS TO CONSIDER WHEN MAKING RESUSCITATION
DECISIONS       36

APPENDIX 6:     ISSUES AROUND INFORMED CONSENT AND CAPACITY               37

BRENT PCT POLICY FOR PROVISION OF FACILITIES FOR CARDIOPULMONARY
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APPENDIX 7:     CARDIOPULMONARY RESUSCITATION DECISION RECORD           40

APPENDIX 8:     CLIENT INFORMATION LEAFLET                              41




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SECTION 1: GENERAL INFORMATION

1.1    INTRODUCTION

Brent Teaching Primary Care Trust is committed to provide the highest quality of care
for all its clients and to uphold the principles laid out in the Human Rights Act 1998 in
considering issues around Cardiopulmonary resuscitation

Provisions particularly relevant to decisions about attempted resuscitation include:
 Article 2: The right to life
 Article 3: The right to be free from inhuman or degrading treatment
 Article 8: The right to respect for privacy and family life
 Article 10: The right to freedom of expression, which includes the right to hold
               opinions and to receive information
 Article 14: The right to be free from discriminatory practices in respect of these
               rights


Cardiopulmonary resuscitation (CPR) can be attempted on any person whose
Cardiac or respiratory functions cease. Failure of these functions is part of dying and
thus CPR can theoretically be attempted on every individual prior to death.

Because for every person there comes a time when death is inevitable, it is essential
to identify patients for whom cardiopulmonary arrest represents a terminal event in
their illness and in whom attempted CPR is inappropriate. It is also essential to
identify those patients who do not want CPR to be attempted and competently refuse
it.

Ideally, decisions about whether to attempt to resuscitate a particular patient, are
Made in advance as part of overall care planning for that patient and, as such are
discussed with the patient along with other aspects of future care.




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RESUSCITATION

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1.2    TERMS USED IN RESUSCITATION

Resuscitation is the term used for the emergency treatment needed to overcome
the failure of breathing and circulation. It may consist simply of opening the airway
and placing the casualty in the recovery position or it may consist of rescue breathing
and chest compressions to maintain circulation.

Cardiopulmonary resuscitation (CPR) is the attempt to restart cardiac and
respiratory function in an individual whose heart or breathing has stopped (cardiac or
respiratory arrest). It is not always successful and the outcome depends in a large
part on the underlying reason for the cardiac or respiratory arrest.

Basic life support (BLS) is the immediate first step in CPR. The purpose of BLS is
to maintain adequate ventilation and circulation until the means can be obtained to
reverse the underlying cause of the arrest. BLS comprises:
 Initial assessment
 Airway maintenance
 Expired air ventilation (rescue breathing)
 Chest compression

BLS implies that no equipment is employed. Where a simple airway or facemask for
mouth to mouth ventilation is used, this is defined as basic life support with airway
adjunct.

Advanced life support (ALS) is when drugs and equipment are used in addition to
chest compressions, not only to maintain circulation and breathing but also to try and
treat any potentially reversible cause. Equipment used may include:
 Defibrillator
 Oxygen
 Bag and mask
 Intravenous lines
 Endotracheal tube
 Intravenous and endotracheal drugs
 Ventilator

Anaphylaxis is the exaggerated response of a previously sensitised individual to
foreign antigenic material. The reaction is of rapid onset and can be fatal.
Anaphylaxis, is frequently due to insect bites, certain food (peanuts, cheese), latex,
blood products, drugs (antibiotics, vaccines, aspirin, local anaesthetics and contrast
media). (See Anaphylaxis policy)

A medical emergency is an acute situation requiring medical intervention but where
cardiac output and breathing have not stopped. Certain areas within the Trust have
developed treatments for foreseeable medical emergencies
E.g. Hypoglycaemia
       Cervical shock or Grand mal in Family Planning, Women‟s services




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1.3      THE SCOPE OF BRENT TEACHING PRIMARY CARE TRUST SERVICES

Brent Teaching Primary Care Trust delivers healthcare to a broad range of client
groups in a number of very different settings. It has the responsibility to provide a
clear policy on resuscitation not only for the benefits of patients and clients, but also
for staff and visitors.

Different settings will require different pathways within the overall resuscitation policy
because of the nature of either the location or the client group. These fall into the
following categories:

     Community hospitals
     Willesden
     Kingsbury

These hospitals have inpatient beds for different client groups; continuing care,
elderly, learning disability, , physical disability, rehabilitation and
There may also be day patients or outpatients visiting for medical appointments or
therapies such as dentistry, occupational therapy, physiotherapy, podiatry or speech
and language therapy.

There is no resident medical staff at these locations.

     Centres for Health and Care
     Wembley

These are “one-stop” centres with longer opening hours and greater access than
health centres. There are no inpatient facilities.

Not all the clinical staff will be employed by Brent Teaching Primary Care Trust.

There will not always be medical staff present for the entirety of the opening hours at
each site.

   Health centres and clinics
These provide GP and community based services to a wide range of clients in a
primary care setting.

Not all the clinical staff will be employed by Brent Teaching Primary Care Trust.

There will not always be medical staff present for the entirety of the opening hours at
each site.


   Special schools
These provide on-site clinical care by doctors, nurses and other health professionals
during school hours to children with learning disability and physical disability.




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  Domiciliary services
Many Brent Teaching Primary Care Trust staff deliver care to clients in their own
homes, including
 Community children‟s nurses
 District nurses
 Health visitors
 School nurses
 Specialist nurses
 Doctors
 Dentists
 Podiatrists
 Other allied health professionals including Occupational therapists, Pharmacists,
   Physiotherapists and Speech and language therapists
 Healthcare assistants


   General public on Brent Teaching Primary Care Trust premises
This group includes anyone who is not a patient or client and for the purposes of this
policy includes visitors, passers-by, members of staff and any others who may be on
the premises.

In some situations clients should be treated in the same way as the general public:
 If they are in a non-clinical area
 If they are in a clinical area where they are not known
    (visiting another ward, attending outpatients etc)


  Brent Teaching Primary Care Trust staff on non-Brent Teaching Primary
   Care Trust premises
Some Brent Teaching Primary Care Trust staff work on non-Brent Teaching Primary
Care Trust premises:
E.g. School nurses in local authority schools
       Specialist nurses in other hospitals (North West London Hospitals)

They should familiarise themselves with local arrangements for calling for help in an
emergency.


  Non-Brent Teaching PCT staff on Brent Teaching PCT premises
Some non-Brent Teaching Primary Care Trust staff work on Brent Teaching PCT
premises.

It is their responsibility to familiarise themselves with the emergency procedures
when working on Brent Teaching Primary Care Trust premises.




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SECTION 2: CARDIOPULMONARY RESUSCITATION

2.1    CARDIOPULMONARY RESUSCITATION PATHWAYS (see Appendix 1)

For different areas the resuscitation pathway followed depends on the location as
well as the availability of equipment and appropriately trained staff.

The clinician with accountability for a patient area is responsible for making the
decision as to which pathway should be followed (see Appendix 1.1)

Each Brent Teaching PCT location must have its emergency procedures and its
minimum pathway clearly displayed and communicated to all staff.

Brent Teaching PCT staff who work at different locations are responsible for checking
where the information is displayed.


Pathway 1A: Basic Life Support (Adult)
Pathway 1B: Basic Life Support (Paediatric)
For use in places where no equipment is available
(see Appendix 1.1)


Pathway 2A: Basic Life Support (Adult)
Pathway 2B: Basic Life Support (Paediatric)
For use in clinical areas where BLS equipment is available but no ALS trained staff is
available
(see Appendix 1.1)


Pathway 3A: Advanced Life Support (Adult)
Pathway 3B: Advanced Life Support (Paediatric)
For use in clinical areas where ALS equipment and appropriately trained staff is
available
(see Appendix 1.1)




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RESUSCITATION

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2.2      EQUIPMENT (see Appendix 2)

On all Brent Teaching Primary Care Trust sites the following standard equipment
should be available:

     Orange bags for BLS including Anaphylaxis kits
      Contents and expiry dates to be checked on the first day of each month
      (see Appendix 2.1 for guidelines, contents, checklist and restocking information)

     Automated External Defibrillators with spare battery pack
      For daily check and annual service

On Brent Teaching PCT sites where ALS trained staff are present, the following ALS
equipment should be available:

     Blue adult cardiac arrest box (see Appendix 2.2 for contents)
      To be checked for intact seal and expiry date on the first day of each month

     Red paediatric cardiac arrest box (see Appendix 2.2 for contents) on Minor
      injuries unit, St Charles hospital
      To be checked for intact seal and expiry date on the first day of each month

  Standard Resuscitation trolley
   Contents to be checked daily
   Expiry dates to be checked on the first day of each month
   (See Appendix 2.3 for procedure, contents, checklist and restocking information)
The Clinician with accountability for the patient area is responsible for making the
decision as to what needs to be kept on the resuscitation trolley.


The resuscitation policy implementation group will advise on equipment, recommend,
review and update at least annually.


2.3 TRAINING

All clinical staff must receive annual training on what to do in an emergency, how to
provide BLS and how to treat anaphylaxis.

All non-clinical staff must receive training on what to do in the event of an emergency
as part of the local induction policy.

All ALS trained staff must update their training every three years.
Wherever possible further training in ALS for clinical staff should be encouraged.


2.4      DOCUMENTATION OF RESUSCITATION INCIDENTS (see Appendix 3)

Resuscitation or CPR attempts following an adverse clinical event must be reported
on the Brent Teaching Primary Care Trust incident form.

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For incidents where BLS is provided, a record for BLS resuscitation must be
completed
(see Appendix 3.1). A copy should be faxed to the hospital where the patient is
taken.

For incidents where BLS and ALS are provided, a record for ALS resuscitation must
be completed (see Appendix 3.2). A copy should be faxed to the hospital where the
patient is taken.

Copies of all incidents should be forwarded to as under the PCT‟s Incident
Management Policy.


SECTION 3: DO NOT ATTEMPT RESUSCITATION (DNAR) ORDERS

This section should be read in conjunction with the Trust‟s Consent to examination
and treatment policy.

3.1      WHAT ARE THEY?

A “do not attempt resuscitation” or DNAR order is an advance decision that CPR will
not be attempted. It should be made only after appropriate consultation and
consideration of all relevant aspects of the patient‟s condition. These include:
 The likely clinical outcome, including the likelihood of successfully restarting the
    patient‟s heart and breathing and the overall benefit achieved from a successful
    resuscitation
 The patient‟s known or ascertainable wishes
 The patient‟s human rights, including the right to life and the right to be free from
    degrading treatment


3.2      WHAT WILL BE PROVIDED IF A DNAR ORDER IS WRITTEN?

A DNAR order only applies to CPR and not to any other form of basic care or medical
treatment, all of which will continue to be actively provided if they are required, unless
specified otherwise in the management plan. These include:
 Nursing care, oral nutrition and hydration
 Suction or airway
 Administration of oxygen
 Positioning for comfort
 Control of bleeding
 Symptom control
 Emotional support
 Continued medical assessment and treatment


3.3      WHAT WILL NOT BE PROVIDED IF A DNAR ORDER IS WRITTEN?

     Chest compressions


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     Respiratory assistance by “mouth to mouth”, bag and mask or other ventilating
      equipment
     Electrical defibrillation / cardioversion


3.4      PRESUMPTION IN FAVOUR OF ATTEMPTING RESUSCITATION

There should be a presumption that health professionals will make all reasonable
efforts to attempt to revive the patient in the following circumstances:
 Where no explicit advance decision has been made about the appropriateness or
    otherwise of attempting resuscitation prior to the patient suffering cardiac or
    respiratory arrest
 The express wishes of the patient are unknown and cannot be ascertained

Senior medical and nursing colleagues should support anyone attempting CPR in
such circumstances.

Although this is a general assumption, it is unlikely to be considered reasonable to
attempt to resuscitate a patient who is in the terminal phase of illness or for whom the
burdens of treatment clearly outweigh the potential benefits.


3.5      IN AN EMERGENCY

If no decision has been made or a decision is not known, CPR should be instituted.

The general public, this includes visitors, passers-by, members of staff and any
others who may be on the premises, will be for CPR.

If a healthcare professional accompanies off-site a hospital patient in whom a
decision has been made and documented, it is the responsibility of the healthcare
professional to make themselves aware of the decision before leaving the hospital
site.

In some cases a decision may have been made but quite appropriately may not be
known to the person witnessing the emergency. If there is any doubt, CPR must be
instituted.




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3.6    WHEN IS IT APPROPRIATE TO CONSIDER MAKING A DNAR ORDER?

This section outlines situations in which it is appropriate to consider making a DNAR
order. It does not define the circumstances in which patients must and must not be
resuscitated. However it attempts to clarify the type of factors that are important in
decisions about whether attempting CPR is appropriate.

Each case involves an individual patient with their own particular circumstances and
it is important to ensure that these circumstances are central to each decision rather
than applying the same decision to whole categories of patients.

A.      Where a competent patient makes an informed decision to either refuse
        attempted resuscitation in advance or consents not to have attempted
        resuscitation
Where competent patients are at foreseeable risk of cardiopulmonary arrest or have
a terminal illness, there should be sensitive exploration of their wishes regarding
resuscitation. This will normally arise as part of general discussions about the
patient‟s care. Information should not be forced on unwilling recipients. If patients
indicate that they do not wish to discuss resuscitation this should be respected.

B.     Where a patient has made an advance directive or living will accurately
       predicting their current clinical picture and declining CPR in such
       circumstances
This can be revoked verbally by the patient at any time.
(see Appendix 4 for further guidance)

C.       Where attempting CPR will not restart the patient’s heart and breathing
If the health care team is as certain as it can be that attempting CPR would not
restart the patient‟s heart and breathing, the patient cannot gain any clinical benefit
from any attempt. Consensus within the team about the likely clinical outcome should
be the aim and the decision-making must be based on clinical assessment of the
patient‟s condition and up to date clinical guidelines.

D.       Where there is no benefit in restarting the patient’s heart and breathing
Although in most cases benefit is gained when a patient‟s heart and breathing are
successfully restarted following cardiopulmonary arrest, this is not true in all cases.
No benefit is gained if only a very brief extension of life can be achieved and the
patient‟s co-morbidity is such that imminent death cannot be averted.
Similarly, no benefit is gained by the patient, if they will never have awareness or the
ability to interact and therefore will be unable to experience benefit.

E.     Where the expected benefit is outweighed by the burdens
Where CPR may be successful in restarting the patient‟s heart and breathing and
thus prolong the patient‟s life, the benefits to be gained from the prolongation of life
must be weighed against the burdens to the patient of the treatment




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SECTION 4: DECISIONS RELATING TO CARDIOPULMONARY
RESUSCITATION

Decisions about attempting resuscitation raise sensitive and potentially distressing
issues for the patient and people close to the patient.

Competent adults
A mentally competent patient has an absolute right to refuse treatment.
It is good practice to discuss the overall management plan including “end of life”
decisions with a competent patient. When patients are seriously ill, the prognosis and
management plan is often discussed with relatives but the competent patient‟s
permission should be sought for this and also their view on who if anyone, they would
like involved in decisions regarding their healthcare.
(see Appendix 5 and 6 for more guidance)

Incompetent adults
For adult patients who are not competent to make decisions for themselves, the legal
responsibility for the decision passes to the doctor, who has a duty to act in their
patient‟s best interests, and not to the family. However the views of the patient‟s
family should be sought as to what they think the patient themself would want.
(see Appendix 5 and 6 for more guidance)

Children and young people
Decisions regarding resuscitation should be taken within a supportive partnership
involving patients, their families and the health care team and should be made
according to the same criteria that govern adults.
Parents are the usual proxy decision-makers for children who are unable or unwilling
to decide for themselves.
Competent young people must be offered the opportunity to participate in decision
making and may give consent to medical treatment. Parents may override a
competent young person‟s refusal of treatment but have a duty to consent to
treatment only if it is in the best interest of the child.
(see Appendix 6 for more guidance)

Terminally ill patients
There is evidence to suggest that for terminally ill patients, the harms of CPR are
likely to far outweigh the possible benefits. There is no ethical obligation to discuss
CPR with the majority of palliative care patients. The raising of such issues may be
redundant and potentially distressing. If the likely outcome of a CPR intervention is
uncertain, a decision regarding resuscitation should be sensitively explored with the
patient and the likelihood of success and resulting quality of life discussed. Should a
patient be likely to benefit from CPR and would wish for it, the extent of CPR facilities
and expertise available should be discussed.
In the absence of a decision or a valid advance refusal at the time of
cardiopulmonary arrest, the patient is by definition incompetent to make a decision
and therefore it is the doctor‟s legal responsibility to act in the patient‟s best interests.




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4.1    RESPONSIBILITY FOR RESUSCITATION DECISIONS

The overall responsibility for decisions about CPR and DNAR orders rests with the
Consultant or General Practitioner in charge of the patient‟s care. They should
always be prepared to discuss the decision for an individual patient with other health
professionals involved in the patient‟s care.

The most senior doctor available should make the decision.
House officers should not make decisions.

The importance of teamwork and good communication cannot be over-emphasised.
In locations with no resident medical staff, the nursing staffs are often in the best
position to explore the feelings of patients and their relatives.


4.2    TIMING OF RESUSCITATION DECISIONS

Inpatients
Inpatients should have a decision made and documented at their medical
assessment on admission.

A DNAR decision should not be documented unless one of the criteria given above
(in section 3.6 / 4) is clearly met.

In most cases, patients are transferred from other hospitals and not admitted directly,
therefore the medical teams should liaise before transfer. Discussion and
documentation of the management plan, including any resuscitation decision in the
transfer information, is mandatory and should be carefully scrutinised by the doctor
admitting the patient.

Outpatients
For outpatients the presumption is always to attempt resuscitation unless a clear
decision to the contrary has been made, documented and is known.

For those patients who do not have serious disease and are at very low risk or
cardiopulmonary arrest, it is inappropriate to discuss resuscitation.

For those patients who are known to have acute or chronic severe illness, or at high
risk of an acute severe event, it is the doctor‟s responsibility to consider the likely
benefit of attempted CPR and open discussion where appropriate.

The entire team should be open to views offered about resuscitation at any time from
patients themselves.

Patients in the community
A decision should be made by the doctor in charge of the patient‟s care and
documented in the patient‟s notes. The decision should be communicated to all
health professionals involved in the patient‟s care.

A decision made as an inpatient should be communicated to the primary care team
or health / social care facility on discharge and recorded in the community nursing


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notes. In addition, for palliative care patients, the decision made as an inpatient
should be communicated to paramedical staff.


4.3      DOCUMENTATION OF RESUSCITATION DECISIONS

A cardiopulmonary resuscitation decision record (see Appendix 7) must be
completed and signed by the responsible doctor following the medical assessment
on admission. The patient may also sign if they wish, however this is not a legal
requirement.

Any supporting discussion including reasons for the decision should be recorded in
the patient‟s notes. Other members of the healthcare team should also sign to
acknowledge the decision. It should also be documented in the separate notes of
each discipline to ensure that all relevant healthcare professionals are aware.

The completed form must be filed in the front of the Brent Teaching Primary Care
Trust records.



4.4      REVIEW OF RESUSCITATION DECISIONS

Decisions about resuscitation must be reviewed regularly. The frequency of review
should be determined by the Consultant or GP responsible and recorded on the
cardiopulmonary resuscitation decision record.

In addition, a review of the decision must be made:
 Following a change in the patient‟s wishes
 Following a change in the patient‟s condition which is likely to change the
    outcome of any CPR attempt
 Following any successful attempt at CPR
 At discharge
     For patients who have chronic or terminal illness who attend frequently,
        especially those attending day care, the future resuscitation status should be
        reviewed as part of the overall management plan. The decision may remain
        valid on discharge. The appropriate section of the cardiopulmonary
        resuscitation decision record should be completed.
     For all other patients, DNAR orders made whilst an inpatient will not be valid
        after discharge. The cardiopulmonary resuscitation decision record should be
        crossed through


SECTION 5: AUDIT

Regular audit with feedback to the resuscitation officer / resuscitation policy
implementation group and the individual services should be carried out for the
following:

     The documentation and basis for DNAR decisions


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   The documentation of resuscitation incidents

   Equipment

   Training


SECTION 6: REFERENCES

Decisions relating to CPR: A joint statement from the BMA, the resuscitation council
UK and the RCN
February 2001
http://www.bma.org.uk/cpr
http://www.resus.org.uk/pages/dnar.htm

BMA practical guide to gaining patient consent
March 2001
http://www.bma.org.uk/public/pubother.nsf/webdocsvw/consentkit

Resuscitation guidelines 2001
Resuscitation council UK
http://www.resus.org.uk/pages/guide.htm

Ethical decision-making in Palliative Care. CPR for people who are terminally ill
National Council for Hospice and specialist Palliative Care services
Joint working party of 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, August 1997
http://www.hospice-spc-council.org.uk/publicat.ons/text/cprethic.htm

Human Rights Act 1998




Further copies of this policy can be obtained from:

Brent Teaching PCT,
A client information leaflet is also available (see Appendix 8)




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Appendix 1.1: CARDIOPULMONARY RESUSCITATION PATHWAYS

Pathway 1A: Basic Life Support (Adult)
Pathway 1B: Basic Life Support (Paediatric)
For use in places where no equipment is available
To include:
Domiciliary services and public areas

Pathway 2A: Basic Life Support (Adult)
Pathway 2B: Basic Life Support (Paediatric)
For use in clinical areas where BLS equipment is available but no ALS trained staff is
available
To include:
Willesden hospital: Young disabled unit (if anaesthetist not present),
                        Fifoot, Furness and Menzler
Kingsbury hospital: Carlton house, Kenton house and the Courtyard
Centres for Health and Care including Occupational health at Wembley
Health centres and clinics including child health, dental, family planning, podiatry and
any other specialist clinic or services

Pathway 3A: Advanced Life Support (Adult)
Pathway 3B: Advanced Life Support (Paediatric)
For use in clinical areas where ALS equipment and appropriately trained staff is
available
To include:
Willesden hospital: Young disabled unit (if anaesthetist present),


Central Middlesex outpatients, chest clinic and X-ray, at Willesden follow their
respective resuscitation policies.




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Appendix 1.1: PATHWAY 1A:          BASIC LIFE SUPPORT (Adult)
   For use in patient’s homes or public places where no equipment is available

                             Ensure safe approach



                             Check responsiveness
                                Shake and shout
                                  Call for help



                                  Open airway
                               Head tilt / chin lift
                      Jaw thrust if neck injury is suspected



                                 Check breathing
                       Look, listen and feel for 10 seconds



      NO
    Dial 999
                                                              YES
                                                   Place in recovery position
                                                  Dial 999 / GP as appropriate
   Give rescue breaths                       Check breathing and pulse every minute
      2 rescue breaths
use pocket mask as available



        Check pulse
    Carotid for 10 seconds
                                                                    YES
                                                   Continue rescue breathing 10 per minute
                                                          Check pulse every minute
                    NO
Start chest compressions 100 per minute
  at ration of 15:2 with rescue breaths



                                  APPENDIX 1
                               CONTINUE UNTIL HELP ARRIVES




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 Appendix 1.1: PATHWAY 1B:          BASIC LIFE SUPPORT (Paediatric)
    For use in patient’s homes or public places where no equipment is available

                               Ensure safe approach


                               Check responsiveness
                                  Shake and shout
                                    Call for help


                                    Open airway
                                 Head tilt / chin lift
                        Jaw thrust if neck injury is suspected


                                    Check breathing
                          Look, listen and feel for 10 seconds


                   NO
                                                                        YES
                                                      Turn child onto their side (not in trauma)
           Second rescuer                                  Dial 999 / GP as appropriate
                                                      Check breathing and pulse every minute

     Yes                        No


                             Give rescue breaths
                   5 rescue breaths (2 of which are effective)
Dial 999             use pocket mask as available covering
                          mouth and nose for an infant


                             Check pulse
                     Child: Carotid for 10 seconds
                    Infant: Brachial for 10 seconds

                                                                             YES
                 NO or BELOW 60                             Continue rescue breathing 10 per minute
     Start chest compressions 100 per minute                       Check pulse every minute
        At ratio of 5:1 with rescue breaths


             Go and dial 999
      after 1 minute of CPR if alone              CONTINUE UNTIL HELP ARRIVES




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    Appendix 1.1: PATHWAY 2A:            BASIC LIFE SUPPORT (Adult)
    For use in clinical areas where BLS equipment is available but no ALS trained staff is
                                          available

                                  Ensure safe approach


                                  Check responsiveness
                                     Shake and shout
                                       Call for help



                                       Open airway
                                    Head tilt / chin lift
                           Jaw thrust if neck injury is suspected



                                       Check breathing
                             Look, listen and feel for 10 seconds



                   NO
                Dial 999
Collect orange bag if not already available
                                                                      YES
                                                           Place in recovery position
         Give rescue breaths                                  Dial 999 as required
            2 rescue breaths                         Check breathing and pulse every minute
Use pocket mask or bag valve mask as per
            rescuer skill level
  Give supplemental oxygen via nipple
        connection as available


             Check pulse
         Carotid for 10 seconds                                          YES
                                                        Continue rescue breathing 10 per minute
                                                               Check pulse every minute
                       NO
   Start chest compressions 100 per minute
      at ratio of 15:2 with rescue breaths

                                   CONTINUE UNTIL HELP ARRIVES




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       Appendix 1.1: PATHWAY 2B:            BASIC LIFE SUPPORT (Paediatric)
        For use in clinical areas where BLS equipment is available but no ALS trained staffs
                                           are available

                                    Ensure safe approach


                                    Check responsiveness
                                       Shake and shout
                                         Call for help


                                          Open airway
                                       Head tilt / chin lift
                              Jaw thrust if neck injury is suspected


                                        Check breathing
                              Look, listen and feel for 10 seconds



                           NO
                                                                                YES
                                                              Turn child onto their side (not in trauma)
                     Second rescuer                                     Dial 999 as required
                                                              Check breathing and pulse every minute

                                         No
             Yes

                                                Give rescue breaths
     Dial 999                       Up to 5 rescue breaths, 2 of which are effective
Collect orange bag            Use pocket mask or bag valve mask as per rescuer skill level
                              Give supplemental oxygen via nipple connection as available


                                                   Check pulse
                                           Child: Carotid for 10 seconds
                                          Infant: Brachial for 10 seconds


                          NO or below 60                                         YES
             Start chest compressions 100 per minute                   Continue rescue breathing
                At ratio of 5:1 with rescue breaths                    Check pulse every minute


Go and dial 999 after 1 minute of CPR if alone          CONTINUE UNTIL HELP ARRIVES




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    Appendix 1.1: PATHWAY 3A:           ADVANCED LIFE SUPPORT (Adult)
     For use in clinical areas where ALS equipment and appropriately trained staff are
                                         available

                                 Ensure safe approach


                                 Check responsiveness
                                    Shake and shout
                                      Call for help



                                       Open airway
                                    Head tilt / chin lift
                           Jaw thrust if neck injury is suspected


                                      Check breathing
                            Look, listen and feel for 10 seconds



                    NO
Call crash team 222 (switchboard to call 999)
 Collect orange bag if not already available

                                                                             YES
                                                                 Place in recovery position
         Give rescue breaths                                   Call on-call doctor as required
            2 rescue breaths                               Check breathing and pulse every minute
Use pocket mask or bag valve mask as per
            rescuer skill level
  Give supplemental oxygen via nipple
        connection as available


            Check pulse
        Carotid for 10 seconds
                                                                         YES
                                                        Continue rescue breathing 10 per minute
                       NO                                      Check pulse every minute
   Start chest compressions 100 per minute
      at ratio of 15:2 with rescue breaths


            CONTINUE AND FOLLOW ALS GUIDELINES WHEN CRASH TEAM ARRIVES




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            PATHWAY 3A TO CONTINUE UNTIL CRASH TEAM ARRIVES




                        ATTACH DEFIBRILLATOR / MONITOR




                       ASSESS RHYTHM AND +/- CHECK PULSE




                                                                   NON VF /VT
       VF / VT




                                  DURING CPR
    Defibrillate x 3
     As required          If not already:
                           Check electrodes / paddle
                              positions and contact
                           Attempt airway and oxygen /
                              IV access
    CPR I minute           Give Epinephrine                       CPR 3 minutes
                              (Adrenaline) every 3                 1 minute after
                              minutes                               defibrillation
                           Correct reversible causes
                           Consider:
                                      Amiodarone
                                   Atropine / pacing


                         Potentially reversible causes
                                    Hypoxia
                                 Hypovolaemia
                                 Hypothermia
                            Tension pneumothorax




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        Appendix 1.1: PATHWAY 3B:           ADVANCED LIFE SUPPORT (Paediatric)
         For use in clinical areas where ALS equipment and appropriately trained staff are
                                             available

                                        Ensure safe approach


                                       Check responsiveness
                                          Shake and shout
                                            Call for help


                                          Open airway
                                       Head tilt / chin lift
                              Jaw thrust if neck injury is suspected


                                             Check breathing
                                   Look, listen and feel for 10 seconds


                         NO
                                                                                    YES
                   Second rescuer                                Turn child onto their side (not in trauma)
                                                                      Call on-call doctor as required
                                                                 Check breathing and pulse every minute
         Yes                                   No


                                                           Give rescue breaths
   Call crash team 222                      Give up to 5 rescue breaths, 2 of which are effective
 (switchboard to dial 999)              Use pocket mask or bag valve mask as per rescuer skill level
Collect orange bag if not                         (covering nose and mouth for an infant)
    already available                   Give supplemental oxygen via nipple connection as available


                                                     Check pulse
                                             Child: Carotid for 10 seconds
                                            Infant: Brachial for 10 seconds

                     NO or below 60                                                 YES
       Start chest compressions 100 per minute                            Continue rescue breathing
           at ratio of 5:1 with rescue breaths                            Check pulse every minute


         Call crash team 222                    CONTINUE THEN FOLLOW ALS GUIDELINES
     after 1 minute of CPR alone                      WHEN CRASH TEAM ARRIVE




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             PATHWAY 3A TO CONTINUE UNTIL CRASH TEAM ARRIVES




                         ATTACH DEFIBRILLATOR / MONITOR




                        ASSESS RHYTHM AND +/- CHECK PULSE




                                                                   NON VF / VT
        VF / VT




                                     DURING CPR
     Defibrillate x 3                                                Epinephrine
      As required            If not already:
                              Check electrodes / paddle
                                 positions and contact
                              Attempt airway and oxygen /
                                 IV access / Intraosseous
     CPR I minute             Give Epinephrine                     CPR 3 minutes
                                 (Adrenaline) every 3
                                 minutes
                              Consider antiarrhythmics
                              Correct reversible cause


                           Potentially reversible causes
                                      Hypoxia
                                   Hypovolaemia
                                   Hypothermia
                              Tension pneumothorax




    Note: First 3 defibrillation shocks: 2J / kg, 2J / kg, 4J / kg
          Second 3 and subsequent defibrillation shocks: 4J / kg, 4J / kg, 4J / kg




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Appendix 2: EQUIPMENT

2.1: ORANGE BAGS FOR BASIC LIFE SUPPORT

Orange bags are designed to keep all equipment required for BLS in the event of a
cardiac arrest or resuscitation incident.

Guidelines
 All staff should be informed of the location of the orange bag on site
 A portable suction unit should be stored with the orange bag and charged
   periodically
 A designated person with a deputy, should be responsible for monitoring the
   contents of the orange bag
 The contents should be checked on the first day of each month using the
   checklist (Appendix 2.1) and the bag resealed.
   A list of contents is in the bag.
   Check oxygen gauge – do not release valve, replace cylinder as necessary
   Check expiry date of anaphylaxis kit and replace as necessary
 The bag should be stored below 25 C, out of direct sunlight, heat and drafts
 Do not lock the bag away
 Do not store the bag on a high shelf
 In the event of a cardiac arrest or resuscitation incident, the bag should be
   completely restocked
 During and following a resuscitation incident, the record for BLS resuscitation
   must be completed. A copy should be:
 sent with the patient or faxed to the acute hospital where the patient was taken
 kept in the patient‟s notes.

Contents                                     Ordering information
Size D oxygen cylinder                       Written request faxed / sent to pharmacy
Hand suction device                          Non-stock requisition
Spare suction catheters                      NHS catalogue
                                             Size 12: FSQ 245
                                             Size 14: FSQ 246
Laerdal pocket mask                          NHS catalogue: FDD 050
Oxygen tubing and mask                       NHS catalogue
                                             Tubing: FDG 337
                                             Mask: FDD 112
                                             Mask with tubing attached: FDD 148
Children‟s oxygen face mask                  NHS catalogue: FDD 651
Gloves                                       NHS catalogue: FTE 749
Pair of scissors                             NHS catalogue: FGP 171
Anaphylaxis kit                              Written request faxed / sent to pharmacy
Record for BLS resuscitation
Contents list




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Appendix 2.1:             ORANGE BAG MONTHLY CHECKLIST

CONTENTS               MONTH:                                                     MONTH:
                       Date checked:                                              Date checked:
                       Complete      Comments / Action            Signature       Complete    Comments / Action   Signature
                         Y/N                                                        Y/N
Oxygen cylinder                   Gauge reading:                                             Gauge reading:
Size D
Hand suction device

Spare suction
Catheters
Laerdal pocket mask

Oxygen tubing &
mask
Gloves

Pair of scissors

Anaphylaxis kit                    Expiry date:                                             Expiry date:

Record for BLS
Resuscitation
Location of bag

Bag resealed

Portable suction                   Charged: Yes / No                                        Charged: Yes / No




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Appendix 2.2:         CARDIAC ARREST BOXES


Blue adult cardiac arrest box
Drug and presentation                                         Quantity

Epinephrine (Adrenaline) injection 1 in 10,000                4
1mg in 10ml pre-filled syringe

Epinephrine (Adrenaline) injection 1 in 1000                  1
5mg in 5ml pre-filled syringe

Atropine injection 3mg in 10ml pre-filled syringe             1




Red paediatric cardiac arrest box
Drug and presentation                                         Quantity

Epinephrine (Adrenaline) injection 1 in 10,000                2
300mcg in 3ml pre-filled syringe

Epinephrine (Adrenaline) injection 1 in 1000                  4
1mg in 1ml pre-filled syringe

Atropine injection 500mcg in 5ml pre-filled syringe           1




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        Appendix 2.3:            RESUSCITATION TROLLEYS

        STANDARD RESUSCITATION TROLLEY

           Contents to be checked daily
           Expiry dates to be checked on first day of the month
           After a resuscitation incident, the contents should be immediately restocked
TOP SHELF AND EXTERNAL FEATURES
Defibrillator / Monitor with ECG leads (dots attached changed every 28 days) and defibrillator pads (AED where
available)
Sharps container
Disposable gloves box (medium size)
Bag-valve-mask resuscitator (single use)
Mouth –to-mask device with oxygen inlet and valve (single use)
Record of ALS resuscitation forms
Eschmann intubation bougie (attached to side of trolley)
Current checklist

1. AIRWAY DRAWER                                                 3. MONITORING EXTRAS
2 x oxygen mask with reservoir                                   3 x IV administration set
1 x oropharyngeal airway (size 2,3,4)                            Pressure infuser bag
1 x nasopharyngeal airway (size 6.0mm, 7.0mm)                    5 x 3 ECG electrodes
1 x laryngeal mask airway (size 3,4)                             5 x 2 Defibrillator gel pads or 2 x 2 AED pads
1 x laryngoscope handle fibreoptic (wash with soap and water)    Adult stethoscope
1 x laryngoscope blade disposable (size 3,4)                     Tough cut scissors
1 x cuffed endotracheal tube (size 6.0mm, 7.5mm)                 Glucose testing sticks (use ward stock)
1 x Portex endotracheal tube stylet (single use)                 Blood sampling bottles (full set)
1 x 20mls air syringe (open, air drawn up, single use)
2 x adult suction yankeur
4 x adult suction catheter aeroflow tip (size 12g,14fg)
1 x endotracheal tube tie (1” gauze)
1 x catheter mount
1 x Magils forceps
10 x non-sterile swabs

2 IV ACCESS                                                      4. EMERGENCY DRUGS
5 x sterile syringes (size 20mls, 10mls, 5mls, 2mls, 1ml)        Hand held suction unit (V-Vac, Rescu-Vac)
4 x venflon catheters (size 20g, 18g, 16g, 14g)                  Additional suction cartridge (single use)
Seldinger CVP catheter pack (16g x 20cm)                         Adult blood pressure sphygmomanometer
2 x Abbocath long neck line (size 14g)                           Adult or Paediatric Cardiac arrest box
2 x Abbocath long neck line (size 16g)                           10 x 10ml Sodium chloride 0.9% injection
2 x 3.0 mersilk suture (W766)                                    Dextrose / saline infusion
4 x IV dressing (current recommendation)                         Sodium chloride 0.9% infusion
Selection of adhesive tape (1.25cm, 2.5cm, 5cm)                  Haemacel / Gelofusine
5 x hypodermic needle (size 19g, 21g)                            2 x 3” non-conforming bandages
4 x three way tap with 10cm extension
5 x blood gas syringe
10 x sterile gauze swab (10 x 10cm)
4 x medicated alcohol wipes (alcowipes)




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Appendix 2.3:         RESUSCITATION TROLLEYS

MOBILE RESUSCITATION TROLLEY CONTENTS LIST

Top and external features
1 x defibrillator / monitor with ECG lead (advisory / quick combo pacing)
Dots to be changed every 28 days
1 x pacing / defibrillator / ECG electrodes
1 x mouth to mask device with oxygen inlet and valve
1 x bag-valve-mask resuscitator (single use)
1 x blue adult cardiac arrest box
1 x oxygen cylinder (size E) with gauge, oxygen tubing and mask
1 x Eschmann intubation bougie (attached to the side of the trolley)
1 x sharps bin (attached to the side of the trolley)
3 x record of ALS resuscitation forms

Drawer 1
1 x Lifepak 9p operating instructions
1 x quick instruction sheet
1 x operators guide for MAC PC ECG machine
1 x checklist for the MRT

Drawer 2
1 x Res-Q-Vac (suction unit)
1 x packet ECG electrodes
1 x box ECG recording paper (number 804700-003)
1 x pacing / defibrillator / ECG electrodes




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      Appendix 2.3: MOBILE RESUSCITATION TROLLEY: ORANGE
      RUCKSACK CONTENTS

      RESUSCITATION TROLLEYS


      Outside top pocket
      1 x clothes scissors
      2 x oxygen masks with reservoir
      1 x manual suction unit

      Outside bottom pocket
      1 x mouth to mask device with oxygen inlet and valve

      Inside SIX zipped bags
IV access                                          Intubation kit
5 x sterile syringes (20ml, 10ml, 5ml, 2ml, 1ml)   2 x laryngeal mask airway (1 x size 3, 1 x size 4)
4 x venflon catheters (size 20g, 18g, 16g, 14g)    2 x laryngoscope handles, fibreoptic
1 x Seldinger CVP catheter pack (16g x 20cm)       2 x laryngoscope blades (1 x size 3, 1 x size 4)
2 x Abbocath long neck line (14g)                  2 x cuffed endotracheal tubes (1 x size 6.0mm,1 x 7.5mm)
2 x Abbocath long neck line (16g)                  1 x Portex E.T. tube stylet
2 x 3.0 Mersilk suture (W766)                      1 x 20mls air syringe (open, drawn up, single use)
5 x IV dressing (current recommendation)           1 x E.T. tube tie
selection of adhesive tapes (1.25cm, 2.5cm, 5cm)   1 x catheter mount
5 x hypodermic needles (size 19g, 21g)             1 x Magils forceps
4 x three-way tap with 10cm short extension        10 x non-sterile swabs
5 x blood gas syringe
10 x sterile gauze swabs
5 x medicated alcohol wipes (alcowipes)

Fluids                                             Airway
3 x IV administration sets                         2 x adult suction catheter, Yankeur
2 x bandage 7.5cm                                  4 x adult suction catheters ( 4 x 12fg, 4 x 14fg)
1 x Sodium Chloride 0.9% injection 1 litre         3 x oropharyngeal airway (1 x size 2,1 x size 3,1 x size 4)
1 x Gelofusine 500mls                              2 x nasopharyngeal airways (1 x size 6.0mm, 1 x 7.0mm)
5 x Sodium Chloride 0.9% injection ampoules        1 x oxygen mask with reservoir

Drugs                                              Bag 6
1 x Atropine 3mg in 30mll                          1 x mouth to mask device with oxygen inlet and valve
5 x Epinephrine (Adrenaline) 1 in 10,000           gauze swabs
1 x Epinephrine (Adrenaline) 1 in 1000
1 x Amiodarone 300mg in10ml




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     Appendix 3.1:          RECORD FOR BASIC LIFE SUPPORT RESUSCITATION


            Date                     Time (24 hour clock)                     Location


        Cardiac arrest                Respiratory arrest                Medical Emergency
          Yes / No                        Yes / No                          Yes / No

            Witnessed     Yes / No                            Mouth to mask    Yes / No

Diagnosis and summary of past medical history




Patient details (use label if available)
Name

Age
Sex                                                           Male / female
Next of kin informed                                           Yes / No
Time ambulance called
Time ambulance arrived
Time BLS stopped
Rationale for stopping



Post arrest destination
Any other treatment given




List of staff involved                     Grade / Position             ALS / BLS trained




Form completed by
Grade / position

    Copies to:     Hospital admitting patient (by fax),

                   Patient‟s notes




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       Appendix 3.2: RECORD FOR ADVANCED LIFE SUPPORT RESUSCITATION

Ward / location:

Time (24 hr clock)              Date                Cardiac           Respiratory         Medical Emergency
                                                     Y/ N                Y/N                     Y/N
Witnessed       Mouth/Mask         Bag & Mask    Intubation    Size E.T.T        Peripheral IV         Central IV
  Y/N               Y/N               Y/N           Y/N                               Y/N                Y/N
No. Drs        No. ALS trained        No. Nurses      No. ALS trained            No. others        No. ALS trained

Diagnosis:                                                               Glucose                   ABG Y / N
                                                                         mmol/l
Patient details (use label if available)                    Additional information:

Name:

Age:

Sex:       M / F

Hospital number:


                Resuscitation details; please give full information on all interventions (with times).
                                      Use additional record forms if required
Time        Rhythm    Thump         Shocks        Epinephrine        Minutes of CPR        Other drugs     Fluids /
                                    (Joules)      (Adrenaline)      after shock/drugs        & dose         Blood




Defib delivered by:        Dr     Nurse    Other            Pacing:        External    internal    PPM

Time CPR stopped                    Rationale                      Post arrest destination
                                                                   CCU         ITU       Mortuary         Other
Form completed by:                                                 Grade / Position


       Copies to:       Hospital admitting patient (by fax),
                        Resuscitation officer / ward manager Allen Daley,
                                                     Patient‟s notes


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                          Appendix 4: ADVANCE STATEMENTS

         (From BMA practical guide to gaining patient consent, March 2001)

1.     What is advance statement?
People who understand the implications of their choices can state in advance how
they wish to be treated if they suffer loss of capacity. An advance statement
(sometimes known as a living will) can be of various types:

   A requesting statement reflecting an individual‟s aspirations
   A statement of general beliefs and aspects of life which an individual values
   A statement that names another person who should be consulted at the time a
    decision has to be made
   A clear instruction refusing some or all medical procedures (advance directive)
   A statement which, rather than refusing any particular treatment, specifies a
    degree of irreversible deterioration after which no life sustaining treatment should
    be given
or
 A combination of the above, including requests, refusals and the nomination of a
   representative

2.      What form should an advance statement take?
An advance statement can be a written document, a witnessed oral statement, a
signed printed card, a smart card or note of a particular discussion recorded in the
patient‟s file.

3.      Who can make an advance statement?
Any person can make an advance statement including an individual under the age of
18, although advance statements will only be legally binding in certain circumstances
(see below).

4.      Are advance statements legally binding?
A clear refusal of treatment by a competent adult, acting free from pressure, has
potential legal force. General statements of preferences should be respected, if
appropriate, but are not legally binding. Any advance statement is superceded by a
clear and contemporaneous decision by the individual concerned. In the case of
young people under the age of 18, advance statements should be taken into account
and accommodated, if possible, but do not necessarily have the same status as
those of adults.

5.      Are all advance refusals of treatment legally binding?
An advance refusal is legally binding providing that the patient is an adult, the patient
was competent and properly informed when reaching the decision, the statement is
clearly applicable to the present circumstances and there is no reason to believe that
the patient has changed his or her mind. If doubt exists about what the individual
intended, the law supports presumption in favour of providing clinically appropriate
treatment, but where the situation that has arisen is clearly that which was envisaged
by the patient, treatment should not be provided contrary to a valid advance refusal.




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Appendix 5: FURTHER POINTS TO CONSIDER WHEN MAKING
RESUSCITATION DECISIONS

(From Decisions relating to CPR; A joint statement from the BMA, the Resuscitation
                            council (UK) and the RCN)

There are many circumstances in which it is justified to attempt to prolong life by
treatment which carries side effects, burdens and risks. Attempted CPR carries a risk
of significant side effects (such as sternal fracture, rib fracture and splenic rupture)
and most patients require either coronary care or intensive care treatment in the post
resuscitation period. If there is delay between CPR and the resuscitation attempt,
there is a risk that the patient will suffer brain damage.
Some resuscitation attempts may be traumatic meaning that death occurs in a
manner the patient and people close to the patient would not have wished. Where
there is a chance of a good or reasonable quality of life being gained, however, most
patients willingly risk some disadvantage. A competent patient is the best judge of
what represents an acceptable level of burden or risk for him or herself, and where
there is a chance of an outcome the patient considers acceptable, many will consider
the risks of even significant disadvantage a burden worth taking.

Where the patient is not competent, any previously expressed wishes should form a
core part of assessing the benefit to that person. As has been noted above,
prolonging life does not always provide a benefit. The courts have confirmed it is
lawful to withhold CPR on the basis that it would not confer a benefit upon the patient
where consideration has been given to the relevant medical factors and to whether
the treatment may provide a reasonable quality of life for the patient. Where patients
suffer with such profound disability that they have no or minimal levels of awareness
of their own existence and no hope of recovering awareness, or where they suffer
severe unmanageable pain or other distress, the question arises as to whether
initiating treatment to prolong their life would provide a benefit to them. In assessing
the benefits that would arise from prolonging life, it is not only legitimate but ethically
appropriate to consider whether cardiopulmonary function is likely to fail repeatedly
and whether there are any costs to the patient in terms of pain or distressing side
effects.

Consideration of the balance of benefits and burdens in these cases involves difficult
matters of balancing rights under the Human Rights Act. The Act guarantees
protection for life (Article 2) but also declares that “no one shall be subjected to
torture or to inhuman or degrading treatment or punishment” (Article 3). Clearly, such
terminology is intended to cover situations in which human beings are deliberately ill-
treated and have severe indignities inflicted upon them. Nevertheless, it should be
borne in mind that some people have a profound abhorrence of being kept alive in a
state of total dependency or permanent lack of awareness. If patients express such
views, health professionals should take note. They should refrain from artificially
preserving life where it is clear that the patient would consider the resulting situation
to be an “inhuman or degrading” state. The duty to protect life must be balanced with
the obligation not to subject the patient to inhuman or degrading treatment.




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Appendix 6: ISSUES AROUND INFORMED CONSENT AND CAPACITY

    (from Decisions relating CPR; A joint statement from the BMA, the Resuscitation
                               council (UK) and the RCN)

Competent adults
People have ethical and legal rights to be involved in decisions that relate to them.
Because patients‟ own views about the level of burden or risk they consider
acceptable carry considerable weight in deciding whether treatment is given, it
follows that decisions about whether the likely benefits from successful CPR
outweigh the burdens should be discussed with competent patients. Thus where
competent patients are at foreseeable risk of cardiopulmonary arrest, or have a
terminal illness, there should be sensitive exploration of their wishes regarding
resuscitation. This will normally arise as part of general discussions about the
patient‟s care. Information should not be forced on unwilling recipients, however, and
if patients indicate that they do not wish to discuss resuscitation this should be
respected. Competent patients should understand that there are opportunities to talk
about attempting CPR, but should not be forced to discuss the issue if they do not
want to. Where a DNAR order is made and there has been no discussion, this must
be documented in the health records and the reasons given. As with any aspect of
care, health professionals must be able to justify their actions.

There is no ethical or legal requirement to discuss every possible eventuality with all
patients, although if patients for whom cardiopulmonary arrest is not a foreseeable
likelihood, do want to discuss resuscitation, the health team must be willing to do this
and to answer any questions honestly.

Any discussions about whether to attempt CPR, and any anticipatory decisions,
should be documented, signed and dated in the patient‟s record.

Incapacitated adults
People close to patients often have the perception that they have the final say about
whether CPR should be attempted, yet in England, Wales and Northern Ireland, no
person is legally entitled to give consent to medical treatment on behalf of an adult
who lacks decision making capacity. Doctors have authority to act in their patient‟s
interests. People close to the patient should be kept informed about the patient‟s
health and be involved in decision making in order to reflect the patient‟s views and
preferences. It should be made clear that their role is not to take the decisions on
behalf of the patient. Relatives and others close to the patient should be assured that
their views on what the patient would want will be taken into account in decision
making but they cannot insist on treatment or non-treatment.

Children and young people
It is recognised widely that medical decisions relating to children and young people
ideally should be taken within a supportive partnership involving patients, their
families and the health care team. The views of children and young people must be
taken into consideration in decisions about attempting CPR.

Competent young people are entitled to give consent to medical treatment, and
where they lack competence it is generally their parents who make decisions on their
behalf. In England, Wales and Northern Ireland, refusal of treatment by competent
young people is not necessarily binding upon doctors since the courts have ruled that

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consent from people with parental responsibility, or the court, still allow doctors to
provide treatment. The Human Rights Act may have implications for such situations,
but at the time of writing these guidelines no relevant legal cases had arisen to clarify
the legal position. Where a competent young person refuses treatment, the harm
caused by violating the young person‟s choice must be balanced against the harm
caused by failure to treat.

Usually agreement will be reached about whether CPR should be attempted if the
patient suffers respiratory or cardiac failure. If disagreement persists despite attempts
to reach agreement, legal advice should be sought. Parents cannot require doctors to
provide treatment contrary to their professional judgment, but doctors will try to
accommodate parent‟s wishes as far as is compatible with protecting the child‟s
interests.

Involving people close to the patient
Despite feeling that they are the natural decision makers, people close to patients
frequently report feeling excluded from a range of decision making. Even where their
views have no legal status in terms of actual decision making, it is good practice to
involve people close to patients in decisions. If the patient is competent, his or her
agreement should be sought. It may also be helpful to ask competent patients who
they want, or do not want, to be generally involved in decision making if they become
incapacitated. Refusal by a competent patient to allow information to be disclosed to
family or friends should be respected. Where an incompetent patient‟s views on
involving family and friends are not known, doctors may disclose confidential
information to people close to the patient where this necessary to discuss the
patient‟s care and not contrary to the patient‟s interests. It is important to be clear that
the information sought from people close to patients, is to help ascertain what the
patient would have wanted in these circumstances, as opposed to what those
consulted would like for the patient, or what they would want for themselves if they
were in the same situation.

Health professionals should be aware that the requirement to respect family life and
impart information, are important human rights considerations. Where patients have
become incapacitated, relatives can provide important information to help ascertain
the patient's prior views about treatment. As noted above, these need to be factored
into any decision but may not ultimately be determinative. The European Court of
Human Rights has taken the view that parents have the right under Article 8 of the
European Convention to be involved in important decisions concerning their children.
By analogy, it is arguable that excluding the family of incompetent patients also
breaches this right unless the patient previously instructed it.

Refusal of treatment
Resuscitation must not be attempted if CPR is contrary to the recorded, sustained
wishes of an adult who was mentally competent and aware of the implications at the
time of making that advance decision. It is well established in law and ethics that
competent adults have the right to refuse any medical treatment, even if that refusal
results in their death. Such a patient‟s informed and competently made refusal which
relates to the circumstances which have arisen, is legally binding upon doctors.
Some patients choose to express their wishes in a written document, an advance
directive or “living will” but it is not necessary for refusal to be in writing in order to be
valid. People often discuss their wishes with a GP or another health professional who
records the discussion in the patient‟s notes. Where patients express a clear and

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consistent refusal, this is likely to have the same status as a written advance
directive.
Patients are not obliged to justify their decisions, but need to ensure that the health
team is aware of them if they are to be implemented. Health professionals usually
wish to discuss the implications of the refusal with patients in order to ensure that the
decision is based on accurate information and not on a misunderstanding, but must
take care not to pressure patients into accepting treatment they do not want.

Refusal of a DNAR order and patient requests for attempted CPR
Some patients may ask for CPR to be attempted, even if the clinical evidence
suggests that in their case it will not effectively restart the heart and breathing or that
it cannot provide any overall benefit. Sensitive efforts should be made without
alarming the patient to convey a realistic view of the procedure and its likely success.
Discussion should aim at securing an understanding and acceptance of the clinical
judgement. If patients still ask that no DNAR order be made, this should be
respected. If a situation in which CPR is a practical option for such patients then
arises, the decision must be made in accordance with the advice in these guidelines.
Doctors cannot be required to give treatment contrary to their clinical judgment, but
should, whenever possible, respect patients‟ wishes to receive treatment which
carries only a very small chance of success or benefit.




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       Appendix 7: CARDIOPULMONARY RESUSCITATION DECISION RECORD

Patient’s surname                        Patient’s forename              Date of birth      Hospital number

In the event of a cardiopulmonary arrest, the above named patient should be:

1.    FOR CARDIOPULMONARY RESUSCITATION                                                                         


2.    NOT FOR CARDIOPULMONARY RESUSCITATION                                                                     
      for the following reason

      Patient decision:
       Patient has given informed consent not to undergo CPR                                                   
       Patient has an advance directive not to undergo CPR                                                     

      Medical decision:
       Where attempting CPR will not restart the patient’s heart and breathing
       Where there is no benefit in restarting the patient’s heart and breathing                               
       Where the expected benefit is outweighed by the burdens                                                 
                                                                                                                

 This decision means chest compressions, assisted ventilation, resuscitative drugs, defibrillation and cardioversion will not
    be provided. All other medical and nursing interventions (see policy for details) may still be provided if appropriate.
Clinician making the decision:
Signature                                                       Print name

Designation                                                     Date

The above decision has been discussed with:                          If not discussed, document reason in medical notes
Patient               Yes             No                              Date
Relatives             Yes             No                              Name (s)                         Date

Parents (for children) Yes                    No                    Date
Key workers informed (please list):




Areas in which decision applies:
Inpatient unit                           Outpatient unit                             Day care unit    

Frequency of review:
Reviews (if CPR status changes, please complete a new form)
         Date                    Signature               Print name                                     Designation




Decision to remain valid on discharge Yes  No 
          Date                    Signature                               Print name                    Designation

       To be copied onto GOLD paper


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Appendix 8: CLIENT INFORMATION LEAFLET

    Draft from the BMA, final version to be included after consultation complete

          Cardiopulmonary resuscitation
Model information leaflet for patients, their relatives,
                friends and carers
  Draft for consultation from the British Medical
              Association May 2001
                                  What is this leaflet about?
                           What is cardiopulmonary resuscitation?
           Is CPR tried on everybody whose heart and lungs stop working?
                                    Where does it happen?
                          Do people get back to normal after CPR?
                        Am I likely to have a cardiopulmonary arrest?
                           What is the chance of CPR reviving me?
                            Will I be asked whether I want CPR?
                           What will be important in the decision?
                                 Does it matter how old I am?
                           What if I can't or don't want to decide?
                                  What if I change my mind?
                          Can my family and friends decide for me?
                             - England, Wales and Northern Ireland
                                            - Scotland
                 If it is decided that CPR is not right for me, what then?
                                 What about other treatment?
         What if I want CPR to be attempted, but my doctor says it won't work?
                              Can I see what's written about me?
 I already know that I don't want my doctors to try to resuscitate me. How can I make
                                        sure they don't?
                               Who else can I talk to about this?


This leaflet explains:
    what cardiopulmonary resuscitation (CPR) is;
    how you will know whether it is relevant to you; and
    how decisions about it are made.

It is a general leaflet for all patients, their relatives, friends and carers, so it may not answer
all your questions - but it should help you to think about the issue. If you have any other
questions, please talk to one of the doctors or nurses (health professionals) caring for you.
They may also have other written information.


What is cardiopulmonary resuscitation?
Cardiopulmonary resuscitation, CPR and resuscitation all mean the same thing - the
emergency treatment used to try to restart a person's heart and breathing if these stop.
When the heart and lungs stop working, it is called cardiopulmonary arrest. CPR might
include:

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       forcefully massaging the chest;
       using electric shocks to start the heart;
       'mouth-to-mouth' breathing; and
       inflating the lungs with a mask or tube inserted into the windpipe to start breathing.

Is CPR tried on everybody whose heart and lungs stop working?
In an emergency, yes. When the heart and lungs stop unexpectedly, for example if a person
has a traumatic accident or heart attack, the health care team try to revive the patient. The
priority is to save the patient's life. The heart and lungs also stop working as part of the
natural and expected process of dying. If patients are already very seriously ill and near the
end of their life, there may be no short- or long-term benefit in trying to revive them each
time their heart fails. This is particularly true when patients have other things wrong with
them that mean they don't have much longer to live. It may be decided that CPR should not
be tried on these patients.
Where does it happen?
Basic CPR can be attempted by any trained person anywhere, including by members of the
public, in an emergency. In hospitals, there are expert teams to do CPR using special
equipment. Ambulance staff, paramedics, and carers in residential care facilities, nursing
homes, special schools and doctors' surgeries will also attempt CPR if necessary. They
usually do not have the same equipment as hospitals.

o people get back to normal after CPR?
Each person is different. Some patients make a full recovery but, unfortunately, CPR does
not always restart the heart and lungs despite the best efforts of everyone concerned. It
depends on why their heart and lungs stopped working and their general health. It also
depends on how quickly their heart and lungs are restarted. The techniques used to restart
the heart and breathing may themselves cause side effects, for example, severe bruising
and fractured ribs. Patients who are successfully resuscitated usually need to be cared for
in a high-dependency unit.

Am I likely to have a cardiopulmonary arrest?
Somebody from the health care team caring for you, probably the doctor in charge, will talk
to you about: your illness;
     what you can expect to happen; and
     what they can do to help you.

Information will not be forced on you, but your doctor may want to tell you the basic facts
about CPR and whether you are at risk of cardiopulmonary arrest. You should not be
alarmed just because CPR is mentioned - it is important that all patients, including those
who are not at immediate risk, know about CPR and have the chance to let the health care
team know what they want.

What is the chance of CPR reviving me?
The chance of CPR reviving you will depend on:
    why your heart and lungs have stopped;
    any illnesses you have; and
    your overall health.

You can talk to your health care team about all of these things. They can also tell you about
any long-term effects, and what you should expect if you are successfully resuscitated.
Statistics show that, on average, fewer than 4 out of 10 patients survive a resuscitation
attempt, and fewer than 2 out of 10 leave hospital after a successful resuscitation. It is

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important to remember, though, that these only give a general picture and not a definite
picture of what you can expect.
Will I be asked whether I want CPR?
When you go into hospital or a residential care home, or register with a family doctor, they
may speak to you about what will happen if you have a cardiopulmonary arrest as part of
general discussions about your health and future care.

If you are at risk of cardiopulmonary arrest, the doctor in charge of your care, or another
senior health professional, will probably want to talk to you about planning for this.

The decision about whether to attempt resuscitation if your heart and lungs stop working is
a very important one, and you should talk to the health professionals caring for you to let
them know what you want. But you don't have to talk about CPR if you don't want to, or you
can put discussion off if you feel you are being asked to decide too much too quickly.

If you agree, your close friends and family can be involved in discussions. (If you are under
the age of 18 (16 if you are in Scotland), your parents will also be involved in the discussion
with the health care team.)

What will be important in the decision?
The health care team will look at the medical issues, including whether CPR is likely to be
able to restart your heart and lungs if they stop, for how long, and whether doing so will
benefit you. Your wishes are very important in deciding whether CPR can benefit you, so if
you have an opinion, you should make sure that somebody in the health care team knows.

Does it matter how old I am?
What is important is:
     you as an individual;
     your state of health;
     what you want; and
     the likelihood of the health team being able to achieve what you want.
Your age alone does not affect the decision, nor does the fact that you may have a
disability.

What if I can't or don't want to decide?
If the team don't know what you want, they will ask people close to you whether they know
what you would want. It is a good idea for you to talk to your friends and relatives
beforehand, so they can pass your wishes on to the health care team. The doctor in charge
of your care must then make a decision about what is best for you.



What if I change my mind?
You can change your mind at any time, and talk to the health professionals caring for you
about resuscitation. The health care team will regularly review decisions about CPR,
particularly if your wishes or condition change.




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Can my family and friends decide for me?
England, Wales and Northern Ireland
If you are over 18, your family and friends are not allowed to decide for you. But it can be
helpful for the health care team to talk to them about your wishes, so they can reach a
decision that is right for you.
If you are under 18, your parents are allowed to make some decisions for you. If there are
people that you do (or do not) want to be asked about CPR, you should let the health care
team know.
Scotland
If you are over 16, you can ask somebody to make decisions for you (a 'proxy') if you cannot
make decisions yourself. If you have not chosen a proxy, your family and friends are still not
allowed to decide for you. But it can be helpful for the health care team to talk to them about
your wishes, so they can reach a decision that is right for you.
If you are under 16, your parents are allowed to make some decisions for you. If there are
people that you do (or do not) want to be asked about CPR, you should let the health care
team know.

If it is decided that CPR is not right for me, what then?
The doctor in charge of your care will make sure that the health care team and the
friends that you want involved in the decision, are told. They will put a note on your
health records that you are „not for cardiopulmonary resuscitation‟. This is sometimes
called a „do-not attempt resuscitation„ order, or DNAR order. It either means that after
assessing all the information, the health team believe that they could not bring you
back to good health if your heart stopped, or you have told them you prefer them not
to attempt CPR.

What about other treatment?
A decision about CPR is about CPR only and does not affect the other care or treatment
you will get. This point is very important - you may not need CPR in any case. You must not
see the fact that doctors may assess resuscitation as likely to fail or likely to leave you in a
very bad condition as giving up. It means that they will put their effort into other care options,
especially keeping you comfortable.

What if I want CPR to be attempted, but my doctor says it won't work?
It often takes time and more than one discussion for people to come to terms with difficult
information. There is nothing more difficult for patients and people close to them than coming
to terms with the fact that all of us eventually reach a point where our hearts stop and we
die. No doctor would refuse your wish for CPR if there were any real possibility of it working
successfully and bringing you back to health. If it might succeed but the likely side effects
are very severe, your opinions about whether these chances are worth taking are very
important. In most cases, doctors and their patients agree about treatment where there has
been good communication. The health care team must listen to your opinions and to the
people close to you if you want them involved in the discussion.

The health care team will arrange a second medical opinion for you if you would like one.
If it is not possible to agree beforehand whether they should attempt CPR, this will be noted
in your records. If an emergency happens, the health care team will make a decision on the
spot, taking account of your wishes and the circumstances at the time.
The demand for every possible treatment, even where the chances of success are
impossibly low, often comes from relatives who have not come to terms with their anxiety,
rather than from patients themselves. The health team must listen to your opinions and
those of the people close to you if you want them involved, but nobody can insist on having

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treatment that will not work. It would also be unfair to other patients, whose lives could be
saved, if they could not get treatment because it was given to somebody else where there
was no chance of success.

Can I see what's written about me?
Yes, you can see what's written about you. The health care team will be happy to show you
your records and, if there is anything in them that you do not understand, they will explain it
to you.

I already know that I don't want my doctors to try to resuscitate me. How can I make
sure they don't?
Talk to somebody in the health care team about your wishes. You could make a living will
(also called an 'advance directive') to put your wishes in writing. If you have a living will, you
should make sure that the health care team knows about it. You should also let people close
to you know so they can tell the health care team what you want if they are asked. The
doctor in charge of your care (usually the consultant in the hospital) will make sure that the
health care team know about your wishes.

Who else can I talk to about this?
The health care team can arrange for a counsellor or spiritual carer (such as a chaplain) to
visit you. If you feel that you have not had the chance to have a proper discussion with the
health care team, or you are not happy with the discussions you have had, please contact ....
who can help and deal with your suggestions, worries or complaints.




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