Towards a national decision form…

1. Towards a national decision form… David Pitcher, Working Group co-chair Alison Richardson, Working Group member

2. Decisions about CPR • Considering • Communicating are challenging • Recording • Misunderstandings • Poor decision-making are common • Communication failures

3. NCEPOD – in-hospital cardiac arrest2011 • Only 22% had a recorded decision about CPR but physiological instability/warning signs in 73% • Many were elderly, had potentially fatal chronic conditions and limited functional capacity • In 196/230 with sufficient data expert advisors felt that DNACPR decisions should have been made • CPR attempted in 52 patients with a DNACPR decision and 7 patients on an end-of-life care pathway

4. Media attention

5. ...presumption in favour of patient involvement... ...anecdotal reduction in DNACPR decisions... ...but surely leaving someone ‘for CPR’ when they may not want it is also a breach of their human rights...

6. October 2014 “…there are clear benefits in having (CPR) decisions recorded on standard forms that are … recognised across geographical and organisational boundaries within the UK.”

7. October 2014 DNACPR from best evidence to best policy and practice

8. Review of DNACPR policies & practice 48 NHS Trusts • 26 acute • 12 community • 10 Ambulance*

9. DNACPR forms in 48 RC(UK) form Modified RC(UK) Bespoke 13% 18% 52% 17% none sent

13. Emergency Care and Treatment Plan (working title) • RC(UK), BMA, RCN - facilitate development of a national form • Broad stakeholder and public/patient engagement • Working group - first met February 2015 • Chairs - David Pitcher [RC(UK)] & JP Nolan [RCN] • First draft July 2015 (‘Personal Emergency Plan’) • Timeline - realistic, pragmatic – 1 year (?)

14. Health Select Committee March 2015 ‘… we recommend that the government review the use of DNACPR orders in acute care settings, including whether resuscitation decisions should be considered in the context of overall treatment plans. This committee believes there is a case for standardising the recording mechanisms for the NHS in England.’

15. ‘ECTP’ should: • be acceptable to - patients - those important to them - health professionals - carers - other members of the public • be underpinned by a good decision-making process • promote good decision-making • promote dialogue between individuals and clinicians • be used across all care settings • be used for individuals of all ages • use evidence and experience from other successful initiatives • consider decisions about CPR within overall goals of care

16. Purpose • To provide immediate guidance to healthcare professionals (and others) • For use when individuals do not have capacity to contribute to a decision • To provide a summary of the anticipatory decisions made. • Not to be a substitute for a more detailed care plan. • For use at all stages of an individual’s ‘journey’ or ‘care pathway’

17. Work in progress...

18. Next steps... • One subgroup working on form design and supporting materials • One subgroup working on consultation, piloting, implementation • Working Group meeting November • Possible appointment of a project manager

19. The way forward... • One subgroup working on form design and supporting materials • One subgroup working on consultation, piloting, implementation • Working Group meeting November • Possible appointment of a project manager • Regard this as a dynamic form/process

20. Avoid... Aim for... Confusion Conflict Chaos Collaboration Consensus Common sense