The subject of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) can be emotionally and professionally challenging, but DNACPR conversations are both a professional responsibility and a public right. A recent feature in the British Journal of Community Nursing (Hadley, 2020) identified barriers to these discussions, including initiating endof-life care conversations, managing patient and family acceptance and confidence and training. The feature reflected on a lack of training for specific DNACPR communication skills and recognised the importance of having these conversations earlier.
News relating to fitness to practice and legal challenges in relation to DNACPR decisions can often lead us to question: what would I have done? In Tracey v Cambridge [2014], it was the CPR decision-making process that was challenged, not the decision to have a DNACPR in place. Headlines at the time inaccurately reported that it was critical to ask permission about CPR, when, in fact, the guidance is to discuss—a subtle but important difference. A recent fitness-to-practice case discussion inferred that not attempting CPR in the absence of a DNACPR form warranted suspension (Nursing and Midwifery Council (NMC), 2020). However, a reading of the full case shows that the suspension was due to lack of evidence of following best-practice guidelines in the use of clinical judgement.
The case highlights challenges in interpreting guidelines and policies, which can appear contradictory; on the one hand, the decision not to commence CPR is supported by guidelines from the British Medical Council et al (2016), which state: ‘If the healthcare team is as certain as it can be that a person is dying as an inevitable result of underlying disease or a catastrophic health event, and CPR would not re-start the heart and breathing for a sustained period, CPR should not be attempted.’ Conversely, local policy, as highlighted in the NMC fitness-to-practice case (NMC, 2020), often states that CPR should be commenced in the absence of a valid DNACPR order.
So, what are the key issues here, and how do we translate them into meaningful learning? First, by earlier identification of patients in the last year of life, campaigns such as ‘Find your 1%’ (Dying Matters, 2018) suggest that tools such as the Gold Standards Framework Proactive Indicator Guidance (Royal College of General Practitioners, 2016) can be embedded into practice. Second, the concept of ‘ordinary dying’ needs to be understood and used to support DNACPR conversations. Sensitively communicating the difference between the final cessation of heartbeat in someone in whom all other vital organs have failed and death from a sudden cardiac event in an otherwise healthy person is key to this process.
Aligned to communication are both education and public understanding—the need to have DNACPR-specific training for professionals before and after registration is a must, and campaigns such as Talk CPR (2020), which promote public conversation about CPR, should be encouraged. Finally, understanding your professional responsibilities, the framework in which you work and the importance of demonstrating and documenting all DNACPR decision-making is critical.
We do have just one chance to get it right. Don't leave it until too late to talk.