Getting DNACPR discussions right
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Getting DNACPR discussions right

Fiona Wilson Lecturer in older people and care, University of Sheffield
Joanne Bird Yorkshire Cancer Research Connects fellow and immunotherapy late effects clinical nurse specialist, Sheffield Teaching Hospitals NHS Foundation Trust

Without the right training and tools, nurses are not equipped to help patients with life-limiting illness say what is important to them

A do not attempt cardiopulmonary resuscitation (DNACPR) notice advises healthcare professionals not to attempt cardiopulmonary resuscitation (CPR) for a person. It is issued and signed by the most senior clinician in charge of the person’s care, which is normally a doctor but can be a senior nurse.

Nursing Standard. 37, 6, 59-59. doi: 10.7748/ns.37.6.59.s22

Published: 01 June 2022

Resuscitation decisions sit within advance – or anticipatory – care planning and should involve individuals and family members in a process of shared decision-making and consideration of patient best interest. However, DNACPR notices can be contentious, requiring ethically informed decisions and a duty of care to involve patients and families.

How many of us would consider a DNACPR notice for ourselves? Or how comfortable would we be in supporting a DNACPR notice for a family member – would it bring a sense of peace or unease?

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Picture credit: iStock

Controversy during the pandemic

DNACPR notices hit the headlines during the first wave of the pandemic. As nurses and researchers in the field of palliative and supportive care, we were particularly aware of the ways media reports presented resuscitation decisions during this time.

Reports circulated of ‘blanket’ resuscitation notices for entire care homes and of those with disabilities undergoing frailty assessments to inform decisions on the use of DNACPR notices and reduce access to acute care. Older individuals keen to ‘do their bit’ were reportedly encouraged to sign DNACPR notices, in something akin to a wartime effort not to waste vital resources. There were also reports of families feeling a sense of guilt that they had ‘signed a DNACPR’ on behalf of a relative.

Used to ‘ration’ access to acute care

We began to systematically record and analyse media reports on the subject of DNACPR notices during the period of March-May 2020. Our analysis found that they were presented by the media as a form of rationing to determine access to acute care, particularly ventilatory support.

The human rights of vulnerable groups were championed in the face of what was reported as discriminatory practice. It also seemed clear that the emphasis on acute care neglected to address palliative care needs, services and support.

Home deaths rose during the pandemic, but it was not clear what support was given to individuals and families, nor what opportunities existed for advance care planning, including resuscitation decisions and palliative care options. The media coverage stimulated a public outcry, culminating in a human rights review of DNACPR decisions and practice during the pandemic.

The resulting Care Quality Commission report highlighted that DNACPR practice during the pandemic left families distressed, with many people also uninvolved in or unaware of resuscitation decisions made on their behalf. It concluded that health and social care workers must be enabled to support those in their care and should also support DNACPR decisions that protect human rights.

The RESPECT tool, which was developed by more than 40 stakeholders including the RCN, supports the deteriorating patient in the acute setting and asks patients to consider what is important to them; intervention or comfort and support. For those with a life-limiting illness, such a dialogue would seem a more holistic approach to shared decision-making than a one-off conversation about resuscitation. Where comfort is the priority, supportive palliative care should be made available.

The training nurses need for these conversations

COVID-19 has highlighted that all health and social care professionals must have the training and skills to support conversations about advance care planning and DNACPR notices, as well as the infrastructure to support communications and care within an integrated care system. The evidence suggests that this seems to be lacking.

It is important that nurses are able to question rather than be complicit in poor practice.

DNACPR discussions should not present as a tick-box exercise, but should provide the basis for compassionate care in the face of life-limiting illness.

Training and support are crucial in developing skills and confidence and we hope that COVID-19 has demonstrated that this should be a priority.

We ask the question again: how many of us would consider agreeing to a DNACPR?

Further information

Ms Bird and Ms Wilson’s study: tinyurl.com/DNACPR-covid-study

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