Pilot of a DNACPR form at

University Hospital Limerick

Denis Casey

End-of-Life Care Coordinator

denis.casey@hse.ie 087 654 4070

Background

• Part 4 of the National Consent Policy

introduced by the HSE(2013) provides a

decision making framework to facilitate

timely discussions with patients regarding

Cardio-Pulmonary Resuscitation (CPR)

• To ensure decisions are made consistently

transparently and in line with the patients

preferences and best practice

• Recognised need to develop a policy for

ULHG

Policy steering group

• Palliative Medicine Cons (Chair)

• Paediatric Consultant

• Medical Consultants x 3

• ED Consultant

• PALS Manager x 2

• EOLC Coordinator

• Resus CNS x 2

• CNM3 Cancer Services

• Clinical Risk Advisor

• Anaesthetic Consultant

Examples of ambiguous documentation

Principles

• DNACPR decisions only related to CPR

• Presumption in favour of CPR if no decision

• Individual assessment of all cases

• Overall responsibility for decision lies with

consultant in charge

• Communication

• ? Valid advance healthcare directive

• ? Power of attorney

• DNACPR order/decision does not override

clinical judgement of a reversible cause

Policy

• Draft Policy developed

• Draft Adult DNACPR Form developed

• Draft Paediatric Advance healthcare Plan

• Decision Making framework

• Patient and Family information booklet

Decision making framework

DNACPR form

Pilot of Form

• Aim of pilot was to test the DNACPR form for

ease of completion and its adoptability among

staff

• It also sought to identify any potential

deficiencies in the policy before being finalised

Methods

• 12 medical consultants volunteered for pilot

Included: Oncology, GI, Renal,

Care of the Elderly, AMAU

• Pilot on 7 Medical wards, ICU & HDU

Results

• Data collection continued for 20 weeks

•289 patients in medical wards, ICU & HDU

documented “Not for resuscitation”

•100 completed forms

Findings

• Capacity

36% had capacity to discuss their status

No patient reported having AHD

No patient reported having EPA

1 ward of court

• Age

Range 53-97, Mean 79

• Discussion

Status was discussed with 31 patients only

Findings

•Reasons not discussed

↓GCS/ Drowsy 9

No Capacity 22

Acutely ill 5

Previously discussed 1

Aphasic 2

Intubated/sedated 1

Findings – Clinical Problems

Subarachnoid Haemorrhage 4

Fraility 27

Dementia 22

ES COPD 9

Cardiac Arrest 1

Hypoxic Brain Injury 1

Multi-organ failure 2

Age 2

Nursing Home resident 3

Parkinsons Disease 8

Congestive cardiac Failure 12

Previous Coronary Bypass graft 1

Stroke 13

ES Renal Disease 11

Cancer 15

Neuro 2

Acute illnesss 6

ES Liver disease 4

Ms/ MND 2

Not complete 7

Findings

• Reasons not for CPR

72% had an advanced progressive illness

59% unlikely to restart heart & Breathing

• Ceiling of Care

Admission to ICU/ HDU

Yes 7%

No 75%

Findings

• Antibiotics

85% were for antibiotic therapy

• IV Fluids

87% were for IV fluids

Findings

• Other

Not for BiPaP 1

Not for intubation 2

For BiPaP 4

Pain/symptom control 5

Dialysis 1

BiPaP if patient wishes 1

Tx for hyperkalaemia 1

Blood products 1

Usual Medications 1

Findings

• Date

35% not dated – invalid

• Signed by Doctor/ Consultant

12% were not signed – invalid

• Signed by nurse

75% were not signed – for communication

Recommendations

• Update draft policy in light of new ADM act 2015

• Date relocated on form to increase compliance

• Increased options ceiling of care

• Policy to be finalised and approved

• To be implemented hospital group wide

Thank you