LPAs, Cars & DNACPR
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DNACPR in the news
You may have noticed headlines about Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) in the past year. As always with news it is the sensationalist headlines that capture the eye and our attention; in issues as important as DNACP knowing the facts behind the headlines matters. This blog explores what DNACPR is and makes clear the role of Lasting Power of Attorney (LPA) with DNACRR.
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation or CPR, is a medical treatment that can be given when you stop breathing (respiratory arrest) or your heart stops beating (cardiac arrest). The purpose of CPR is to re-establish breathing and heartbeat.
CPR can include:
chest compressions: pressing down hard on your chest repeatedly
a machine to stimulate your heart using electrical shocks
artificial ventilation via equipment that helps move oxygen around your body
giving medicine by injection
CPR sometimes results in starting the heart and breathing with the best chance of success if your heart, lungs and general health are good, you are near someone trained in CPR and necessary equipment (such as a defibrillator) is to hand. CPR is less likely to re-establish breathing and heartbeat if you already have organ damage, a severe illness, are frail or approaching the end of life.
It is important to remember that CPR is a medical treatment and, like all treatments, not suitable for all people or all conditions. CPR was introduced in the 1960s as treatment for sudden cardiac arrest most commonly caused by acute myocardial infarction (known as a heart attack). CPR as treatment for a sudden cardiac arrest remains the situation most likely to be successful.
The media and CPR
Most people will not witness a cardiac arrest in reality; instead, the media provides a reference point of belief. I admit to Holby City being by my medical drama of choice (though goodness knows why, I spend too much time being cross with it). I haven’t captured accurate survival numbers on the programme numbers but I do know that the brutality and reality of CPR is not shown. Research supports that Patients overestimate the success of CPR and cites unrealistic television drama as a cause.
Ordinary Dying
Having established what CPR is and when it can sometimes be an effective medical treatment, we move to explore CPR in Ordinary Dying. In each one of us our hearts will take a final beat in the natural process of dying. CPR was not designed for nor is a treatment for Ordinary Dying in which not just the heart, but other organs will have failed. It can be summarised as the difference between the heart being the first organ to stop (in a sudden heart attack) or the last organ to stop (in Ordinary Dying). There are some excellent sources
that explain the concept in a variety of ways and one I particularly love is the Paper Boat analogy by @Trisha_the_doc The image of a beautiful but fragile paper boat is used in this story to represent a picture of declining health increasing less able to weather a storm. My contribution to describing Ordinary Dying developed in response to a family experience. This isn’t so beautiful and is likely technically inaccurate, but worked for us; bear with me as I use the Car Story
The car Story
Imagine a car, bright and shiny and not long out of a showroom – suddenly this car won’t start. Simple problem to fix, the spark plug needed replacing; once sorted the car is as good as new as no other part was broken or worn out. Now imagine a different car, this one has been a super car over many years transporting it’s owner to work, taking long family trips and responding reliably to many family crises. This car has been well looked after and loved but it’s bodywork is rusty, the exhaust is damaged, the head gasket and now the big end too has failed. Fixing a spark plug will not mend the multiple damages to this fine car.
Whilst not mechanically accurate I hope it paints a picture to describe the difference between cardiac arrest and Ordinary Dying.
DNACPR
When CPR will not be an appropriate or effective medical treatment a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) is used to ensure that a person is not subjected to CPR. This can be an important part of planning ahead for some people and part of a much wider discussion about a treatment plan that built around What Matters Conversations A DNACPR is not about denying treatment or withdrawing care and applies only to CPR. If someone, for example, has expressed a wish to be at home to die and is reaching the last few months or weeks of life then a DNACPR decision would be part of a good personalised plan.
DNACPR discussion
A DNACPR is usually a form, signed by the most responsible clinician caring for a patient. As part of the form, the clinician MUST discuss DNACPR with the patient (or those close to the patient if the patient does not have capacity). The emphasis is on discuss not ask; this is a sensitive discussion about values, beliefs and wishes as well as appropriate medical care. Too often I have heard a patient or relative asked; “do you want to be resuscitated?” I cannot begin to imagine the burden this must place on a family member. In a situation where a patient has expressed a wish to stay at home, not to go to hospital to ask “do you want to be resuscitated?” is wholly inappropriate. More appropriate is describing that, as part of care, CPR is not an appropriate treatment whilst reassuring the patient and family of all the things that are still being done to optimise care and comfort.
Lasting Power of Attorney and DNACPR
In line with all medical treatment, there is no right to demand a treatment that is medically inappropriate. A simple example is you cannot ask for antibiotics to treat a viral infection for which the antibiotics won’t work. As a patent you cannot demand CPR although you should be involved in discussions. You can formally refuse the treatment of CPR by making an Advance Decision to Refuse Treatment
“If you wish to make your refusal of CPR legally binding for when in the future you are unable to make this decision, then you should write an Advance Decision to Refuse Treatment (ADRT). An ADRT explains to a doctor or medical team when you want to refuse CPR (or other treatments)”.
NHS: Do not attempt cardiopulmonary resuscitation (DNACPR) decisions
A Lasting Power of Attorney (LPA) is a legal document that states who you have chosen to make decisions for you if you are unable to make that decision yourself, or ‘lack capacity’. The person you choose is referred to as the attorney. If you have made an LPA for Health and Welfare decisions with the option for your attorney(s) to make life sustaining decisions your attorney can refuse CPR on your behalf however they cannot demand it as a treatment. In March 2021 updated guidance NHS DNACPR guidance made explicit the role of attorneys in CPR:
“An LPA (with the right to make decisions on life-sustaining treatment) means your attorney can make the decision to refuse CPR for you in the same way you might decide for yourself if you were able to make life-sustaining treatment decisions. Your attorney cannot insist on CPR being given”.
NHS: Do not attempt cardiopulmonary resuscitation (DNACPR) decisions
Protect, respect, connect–decisions about living and dying well during COVID-19
The CQC: Protect, respect, connect – decisions about living and dying well during COVID-19 review (March 2021) highlighted the role DNACPR discussions have as part of good Advance Care Planning. The report also cited examples of poor practice which included DNACPR decisions as part of a blanket policy or based inappropriately on age or Learning Disability which is against all good practice and guidance.
The report suggests three areas there needs to be improvement on nationally:
1. Information, training & support
2. A consistent national approach to advance care planning
3. Improved oversight & assurance
I welcome the suggestions and the direction the report gives to improving practice, whilst noting with sadness the sensationalist reporting at the time. The report raises the profile of good DNACPR decision making for both the public and professionals and will provide a platform for improvement in education, national documentation and how we check the quality of DNACPR decisions to be assured they are non-discriminatory and in line with guidelines.
Key points
CPR is a valuable medical treatment for a very specific situation, not a cure for Ordinary Dying. Raising awareness both publicly and professionally about the role DNACPR has to play in Advance Care Planning is needed and I suggest in an earlier blog that Advance Care Planning is just one part of part of Normal Life Planning
To summarise:
1. You have the right to be consulted about but not to demand CPR
2. CPR is not an appropriate treatment for Ordinary Dying
3. An attorney can refuse but not demand CPR for you
DNACPR is an emotive subject I am happy to answer questions in more detail, provide education or support in making an LPA.
Further reading & resource
DNACPR details are only touched upon in this blog. More information can be found:
Publication: Decisions relating to cardiopulmonary resuscitation (3rd edition - 1st revision)