“The problems generated by decisions whether or not to impose [Do–not-attempt-CPR] DNACPR notices are inherently fraught”.
Introduction:
In 2014 a judgment by the Court of Appeal stated: “The problems generated by decisions whether or not to impose [Do–not-attempt-CPR] DNACPR notices are inherently fraught. The question whether to consult and notify the patient is inevitably one of the utmost sensitivity and difficulty. Whether it is appropriate to consult will depend on a difficult judgment to be made by the clinicians. The decision will be difficult and sometimes controversial…” R (On behalf of David Tracey personally and on behalf of the Estate of Janet Tracey (Deceased)) v (1) Cambridge University Hospitals NHS Foundation Trust (2) Secretary of State for Health [2014] EWCA Civ 822:54
In the world of healthcare, few decisions are as fraught with complexity and ethical considerations as those involving cardiopulmonary resuscitation (CPR) and Do Not Attempt CPR (DNACPR) orders. A recent case brought to light by a Blog: Reflections on recent CPR fitness to practise case – The Nursing and Midwifery Council (nmc.org.uk) by Andrea Sutcliffe, Chief Executive and Registrar of the Nursing and Midwifery Council (NMC) in the UK, has shed light on the nuances and challenges associated with these decisions. This article delves into the intricacies of CPR and DNACPR, exploring the key takeaways from the case and the broader issues it raises.
The Case of Mrs. Nahid Nasiri:
The case under discussion involves Mrs. Nahid Nasiri, a nurse who faced criticism for her actions in a care home where she did not initiate CPR on an 89-year-old resident who had rapidly deteriorated. The case resulted in Mrs. Nasiri’s 12-month suspension from the nursing register. The circumstances were complex, and the case has triggered important discussions about best practices in CPR and DNACPR decision-making.
In finding that she should have attempted to undertake CPR, they said this:
“The panel acknowledged that Mrs Nasiri was not charged with causing Resident A’s death. The panel also considered the document from the Consultant Histopathogist Page 5 of 13 which states ‘… Resuscitation is unlikely to have been successful’. However, the panel considered that Mrs Nasiri could not be aware of the likely outcome of resuscitation at the time Resident A ceased breathing. The panel considered that Mrs Nasiri should have attempted CPR at the point she realised Resident A had ceased breathing to try to preserve her life in accordance with the Home’s policy, and in respect of the rights of Resident A’s who did not have a DNAR in place”.
In this case, the panel’s ruling reveals that four days prior to the incident, the GP had expressed concerns about the resident’s declining health and had recommended a discussion regarding a DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) with her. However, this crucial conversation had not occurred, and the resident did not have a documented DNACPR in place when the incident occurred. It is evident that had this discussion taken place and been properly recorded, Mrs. Nasiri would have been able to act in accordance with the resident’s wishes. This situation underscores the critical importance of conducting these challenging conversations and underscores the responsibility of all care providers, especially when individuals are nearing the end of their life.
On review of her case after her suspension, the NMC decided to strike her off from the register all together citing the following:
“Regarding insight, the panel found that from the documentary evidence before it that Mrs Nasiri has not shown insight. The panel considered that it did not have any reflective piece from Mrs Nasiri before it. The panel considered that Mrs Nasiri’s representative submitted representations on her behalf during the regulatory investigations which stated, ‘lessons were learned from this incident, any decision she made at the time of the incident was a ‘sound and legitimate clinical decision’. However, the panel noted that Mrs Nasiri has not elaborated on what lessons she learned and how she would deal with a similar situation in the future. The panel noted that Mrs Nasiri has not provided evidence to demonstrate the effect her actions had or could have had on patients or the family of Resident A. It further considered that Mrs Nasiri has not demonstrated how her actions affected or could have affected her colleagues and the wider profession”.
What does the guidance say:
The document titled “Decisions relating to cardiopulmonary resuscitation: Guidance from the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing” is a vital resource designed to assist healthcare professionals in the United Kingdom when facing difficult decisions related to cardiopulmonary resuscitation (CPR).
The guidance advises:
“Considering explicitly, and whenever possible making specific anticipatory decisions about, whether or not to attempt CPR is an important part of good-quality care for any person who is approaching the end of life and/or is at risk of cardiorespiratory arrest.”
This document highlights the importance of establishing clear policies for making decisions about cardiopulmonary resuscitation (CPR) in various healthcare settings, including hospitals, general practices, care homes, hospices, and ambulance services, in the United Kingdom. These policies should be easily accessible, well understood by relevant staff, and made available to the public.
Lessons from the Case:
- Importance of Clear and Informed Decisions:
“Every decision about CPR must be made based on a careful assessment of each individual’s situation. These decisions should never be dictated by ‘blanket’ policies.”
One of the primary takeaways from this case is the significance of making clear, informed decisions regarding CPR and DNACPR. Healthcare professionals must base their choices on a careful assessment of everyone’s situation rather than following “blanket” policies. It is crucial to consider the patient’s specific condition, medical history, and end-of-life wishes when determining whether to attempt CPR.
However, the starting point of your decision is:
“Where no explicit decision about CPR has been considered and recorded in advance there should be an initial presumption in favour of CPR. However, in some circumstances where there is no recorded explicit decision…a carefully considered decision not to start inappropriate CPR should be supported.”
- The Need for Open Communication:
The case highlights the importance of open communication regarding end-of-life care decisions. It was found that a discussion about a DNACPR order had not taken place with the resident involved. Despite the suggestion from a GP that it should. Effective communication between healthcare providers, patients, and their families is essential to ensure that everyone is on the same page and that the patient’s wishes are respected.
- The importance of evidencing your decision making:
Effective and comprehensive documentation not only serves as a record of your decision but also supports transparency, accountability, and continuity of care. It ensures that all stakeholders, including other healthcare professionals and legal authorities, can understand the rationale behind the decision and, if necessary, conduct reviews or investigations. Moreover, it respects the patient’s right to have their wishes and best interests documented and considered in their care plan.
Documenting your decision is paramount. The rationale behind the decision not to perform CPR should be clearly and comprehensively recorded in the patient’s medical records. This includes details of the discussions held, any expressed or inferred patient wishes, and the clinical reasons for the decision.
When in doubt or when the decision is particularly complex, it is advisable to consult with colleagues or senior healthcare professionals. Collaboration and seeking a second opinion can help ensure that the decision aligns with best practice and ethical standards.
Ensure that your decision documentation shows compliance with ethical and legal standards. It should prioritise the patient’s autonomy, dignity, and best interests while considering the legal and regulatory requirements, including the NMC Code of Practice.
- Engaging with the Fitness to Practise Process:
When healthcare professionals are referred to a fitness to practise process, it is vital for them to engage with the proceedings. This engagement allows for a fair assessment of the case and provides an opportunity for the registrant to present their side of the story. It’s a challenging process, but it’s crucial to ensure transparency and fairness.
One of the take-homes from this case was that the conduct was easily remediable through training. The mistake, or lack of evidence to support the decision did not have to lead to a striking off order. The nurse could have undertaken reflection and training, or indeed would have had more chance of no sanction had she engaged with the process.
“She (the Case Presenter) submitted that the misconduct occurred during clinical practice, and it is possible to carry out targeted specific training, reflection and supervision to demonstrate that the clinical failings have been addressed.”
We would refer you back to our previous guide on how to navigate the FtP process to get best results. But the take home here is that it does not need to be the end of your career even if you get it wrong. In this case a reflection, using the Gibbs reflective cycle could look like:
The Gibbs Reflective Cycle is a structured approach for self-assessment and learning from past experiences. Applying this model to a scenario involving a nurse’s decision-making process and actions can help identify areas for improvement and enhance their practice. In this case, we’ll use the cycle to evaluate the actions of a nurse involved in a patient’s care. Here’s a reflective analysis:
“**1. Description (What Happened):**
In this specific case, I was in the role of a nurse responsible for a patient who required cardiopulmonary resuscitation (CPR). The challenge I faced was the absence of a clear, documented Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order for the patient.
**2. Feelings (What Were You Thinking and Feeling): **
During this experience, I recall a mix of emotions. There was a deep sense of uncertainty, given the high-stress nature of the situation. The absence of a documented DNACPR order added to my anxiety, as I grappled with the challenge of making a crucial decision in a time-sensitive and emotionally charged environment.
**3. Evaluation (What Was Good and Bad About the Experience):**
**Positive Aspects:**
– I recognised the significance of having a documented DNACPR decision in place.
– It was evident that my intentions were to act in the best interests of the patient, taking into consideration the circumstances at hand.
**Areas for Improvement:**
– In hindsight, I believe there were several areas where I could have performed better. Firstly, I should have taken more proactive steps to discuss and document the DNACPR decision with the patient or their designated decision-maker well before this critical moment. This advance planning would have reduced the pressure and ambiguity during the crisis.
– My communication with the healthcare team could have been more comprehensive. To ensure a shared understanding of the patient’s CPR status, I should have facilitated a more detailed and clear exchange of information with other relevant staff members.
– Additionally, I could have considered involving the patient or their family in the decision-making process, as their perspectives and preferences are invaluable. This approach would have respected their autonomy and contributed to a more patient-centred care plan.
**4. Analysis (What Sense Can You Make of the Situation):**
Upon reflection, it becomes apparent that the absence of a documented DNACPR order represented a significant challenge. It underscored the critical need for proactive and thorough communication with patients and their families regarding end-of-life care preferences. As a nurse, my responsibilities extend beyond mere recognition of the need for a DNACPR order; I must actively facilitate discussions and meticulously document the decision.
**5. Conclusion (What Else Could You Have Done):**
In a similar situation, I now understand that there are several proactive steps I could have taken:
– I could have initiated discussions about end-of-life care and CPR well in advance, ideally as part of the advance care planning process. This would have provided the patient and their family with ample time to make informed decisions, reducing the stress during an emergency.
– It is essential to ensure that the patient’s preferences, values, and beliefs are meticulously documented in the medical records, leaving no room for ambiguity.
– In terms of collaboration and communication with the healthcare team, I now recognize the importance of fostering a more efficient exchange of information to prevent misunderstandings or misinterpretations of the patient’s wishes.
**6. Action Plan (If It Arose Again, What Would You Do):**
Looking forward, I am committed to taking the following actions:
– I will proactively engage in discussions with patients and their families about CPR and end-of-life care preferences, ensuring these discussions take place well in advance of any crisis.
– I will ensure that all relevant documentation is kept up to date and accurately reflects the patient’s choices and the agreed-upon care plan.
– To promote better collaboration and communication with the healthcare team, I will actively work on enhancing communication practices to prevent misunderstandings and ensure that everyone involved is well-informed about the patient’s preferences and care plan.
By engaging in this reflective process, I am committed to learning from my experiences, identifying areas for improvement, and enhancing the quality of care I provide”.
- Responsibility of Healthcare Services:
The case also underscores the responsibility of healthcare providers to facilitate difficult conversations about end-of-life care. This includes discussing and documenting DNACPR decisions and making sure that they are clearly understood by all involved. Organisations and professionals should prioritise these conversations to ensure the best possible care for patients approaching the end of their lives.
Conclusion:
The case of Mrs. Nahid Nasiri serves as a stark reminder of the complex and sensitive issues surrounding CPR and DNACPR decisions. Healthcare professionals must navigate these decisions with care, considering the individual circumstances and wishes of the patient. Clear communication, engagement with the fitness to practise process, and a commitment to patient-centred care are essential for ensuring that healthcare providers uphold the highest standards and provide the best possible care, even in challenging situations. Ultimately, this case offers valuable lessons for healthcare professionals and organisations as they strive to provide compassionate and effective end-of-life care.