Resuscitation manual

1 Introduction

The decision and procedure to resuscitate, or not when there is a valid do not attempt cardio-pulmonary resuscitation (DNACPR) decision in place for both adults and children within RDASH are all in one manual. The introduction of, and rationale for, each procedure will be within the relevant chapter.

2 Purpose

The purpose of this manual and the linked procedure documents is to provide clear, concise guidance on managing, for both adults and children:

the risks associated with resuscitation
the systems in place to support effective resuscitation provision
the deteriorating patient
DNACPR decision
recommended summary plan for emergency care and treatment (ReSPECT)

The manual outlines the duties and responsibilities of the trust to comply with the relevant local and national legislation and guidance and monitor compliance with this manual so that an effective service is provided.

3 Scope

This manual applies to all managers with responsibilities derived from it, and all staff (clinical and non-clinical), including bank, agency and temporary staff who may need to summon help if they come in to contact with a patient, visitor or member of staff who becomes acutely unwell.

4 Responsibilities, accountabilities and duties

4.1 Chief executive

The chief executive is responsible for making arrangements to support the safe and effective implementation, monitoring and review of this policy manual.

4.2 Medical director and chief operating officer

These directors are responsible for implementation and monitoring of the policy manual within their areas of responsibility.

4.3 Consultants and medical officers

Consultants and medical officers in charge of patients’ care retain overall responsibility for the decisions relating to procedures within this policy manual.

4.4 Resuscitation committee

The resuscitation committee are responsible for reviewing the trust’s assurance processes within this policy manual and to oversee the annual audit work plan adhering to the UK Resuscitation Council Quality Standards (see appendix A).

4.5 Resuscitation service

Liaise with managers or modern matrons to formulate suitable staff training programmes to support effective implementation of this policy manual.
Deliver training using the current national guidelines.
Maintain a central record of training delivered and produce reports on training compliance.
Discuss with the managers or modern matrons the approach to be taken with staff who do not successfully complete the training assessments.
Act as specialist advisors to the trust on resuscitation and related matters.
Produce an annual audit of resuscitation events, resuscitation equipment, choking incidents and DNACPR or ReSPECT orders
Produce a quarterly audit report on the continual availability of equipment, see appendix D, emergency equipment required in healthcare areas.
Facilitate policy and practice development and organisational learning as a result of audit.
Support Managers in facilitating an environment where incidents are reviewed in an open and positive manner, involving staff at all levels in improving practice and promoting organisational learning
Be available as a source of specialist advice and support to managers and staff, including incident debriefing.
Represent the trust on the regional DNACPR working party and the Doncaster locality End of Life group as the DNACPR lead for the trust.
Lead the review and updating of this policy.

4.6 Managers or modern matrons

Disseminate, implement and monitor implementation of this policy manual within areas of responsibility.
Facilitate, support and monitor ward or team managers in their responsibilities with regard to policy implementation and monitoring.
Identify and allocate resources in order to comply with this policy manual.
Make available appropriate and suitably maintained resuscitation equipment, maintaining up-to-date medical devices inventories in all areas of responsibility.
Promote incident reporting and audit requirements as specified within the policy through local induction processes in all areas of responsibility.
Facilitate an environment where incidents are reviewed in an open and positive manner, involving staff at all levels in improving practice and promoting organisational learning.
Proactively seek advice and support from the resuscitation service.

4.7 Ward or team managers

Facilitate effective local induction processes for all new starters
Manage the process of releasing staff for training and updating at least annually in the skills relevant for their area, in line with the mandatory risk management training policy.
Maintain staff training records for the area, including temporary, bank and agency staff.
Proactively identify risks due to lack of training or resources to the manager or modern matron.
Manage and maintain the resuscitation equipment within the area of responsibility via:
- an up-to-date medical devices Inventory
- signed and dated daily and weekly equipment check records (as per requirements set out in appendix D continual availability of equipment, see appendix D, emergency equipment required in healthcare areas), in line with the manufacturer’s recommendations. A record of these checks will be kept for 3 years
- report any equipment issues immediately to the manager or modern matron
- adequate stocks of disposable or single use parts of the resuscitation equipment required in that area, such as pocket masks, oxygen masks, airway tubes, defibrillator pads etc. to maintain continued functioning of the equipment by immediate replacement
Maintain the equipment ready and available for use for another event as soon as practicable after a resuscitation attempt where the equipment is used.
Make timely arrangements for staff involved in a resuscitation event to be supported, debriefed, and offered counselling as required in conjunction with the resuscitation officer.
Facilitate an environment where incidents are reviewed in an open and positive manner, involving staff at all levels in developing policy and practice and promoting organisational learning.
Proactively seek advice and support from resuscitation service.

4.8 Clinical and non-clinical staff

Adhere and implement this policy manual within the scope of their job role (the resuscitation council expects all staff to recognise cardiac arrest, to commence cardio-pulmonary resuscitation (CPR) and call for help).
Report any issues which affect the effective implementation of this manual to their manager, for example, access to training or equipment.
Report all incidents as per the incident reporting policy including the use of the appropriate cardiac arrest report form.
Maintain a personal record of their own training.
Contribute to the review of incidents in an open and positive manner in order to improve practice and promote organisational learning.

5 Procedure or implementation

6 Training implications

In adherence with the expectations of the Resuscitation Council UK, all staff should have basic knowledge and skills in resuscitation. All staff should be equipped to recognise cardiac arrest, to commence CPR and call for help. All staff should attend, as a minimum, community life support (CLS) every 12 months.

All registered nurses, doctors, and nursing assistants working in areas where physical restraint, rapid tranquilisation or seclusion may be required, will be trained to a level equal to the Immediate Life Support (ILS) course of the Resuscitation council UK. This will be repeated every 12 months.

All registered nurses and nursing assistants working within areas with immediate access to a defibrillator will be trained to the equal level of the immediate life support course of the Resuscitation Council UK. This will be repeated every 12 months.

When practicable and appropriate, the training will be contextual, and scenario based. Staff who do not successfully complete the training assessments will be recalled within 1 month for further training. Failure to complete the assessments after 3 attempts will be discussed with the manager by the resuscitation service.

Basic training on DNACPR and ReSPECT will be within the CLS and ILS sessions. For clinicians who have such discussions within their job roles (includes some specialist nurses identified in the resuscitation committee), additional training is required (See DNACPR and ReSPECT sections)

The Yorkshire and Humber e-learning is an excellent source of information and can be used as a training resource in team meetings etc. It can also be used as an individual training resource and can be found on the trust eLearning platform.

6.1 All non-clinical and community clinical staff CLS training (includes DNACPR or RESPECT)

How often should this be undertaken: 12 months.
Length of training: 3 hours.
Delivery method: Face to face.
Training delivered by whom: Resuscitation service.
Where are the records of attendance held: ESR.

6.2 All in-patient clinical staff ILS training

How often should this be undertaken: 12 months.
Length of training: 3 hours.
Delivery method: Face to face.
Training delivered by whom: Resuscitation service.
Where are the records of attendance held: ESR.

6.3 Clinicians that have escalation plan discussions in Care groups that have ReSPECT, ReSPECT, e-learning

How often should this be undertaken: One-off
Length of training: 40 minutes
Delivery method: E-learning, ReSPECT (opens in new window)
Training delivered by whom: Resuscitation Council UK
Where are the records of attendance held: ESR.

6.4 Clinicians that have escalation plan discussions in Care groups that have ReSPECT

How often should this be undertaken: One off and more if required.
Length of training: 1 hour.
Delivery method: Face to face clinical supervision for additional sessions.
Training delivered by whom: Nurse consultant in palliative care. consultants in older peoples mental health.
Where are the records of attendance held: ESR.

6.4 For care groups that do not have the ReSPECT document

Clinician completing DNACPR decisions, see link above.

How often should this be undertaken: One off.
Length of training: 1 hour.
Delivery method: E-learning.
Where are the records of attendance held: ESR.

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as:

all user emails for urgent messages
one to one meetings or supervision
continuous professional development sessions
posters
daily email (sent Monday to Friday)
practice development days
group supervision
special meetings
intranet
team meetings
local induction

7 Monitoring arrangements

7.1 Policy implementation

Policy implementation including:
- requirement for a documented plan for vital signs monitoring that identifies which variables need to be measured, including the frequency of measurement
- use of an early warning system within the trust to recognise patients at risk of deterioration
- actions to be taken to minimise or prevent further deterioration in patients
- how the trust documents that resuscitation equipment is checked, stocked and fit for use
- incident reports of resuscitation events
- incident reports of choking situation events
- staff training, as identified in the training needs analysis
How: Resuscitation audit.
Who by: Resuscitation officer.
Reported to: Quarterly and annually.
Frequency: Resuscitation committee.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

There are no additional requirements in relation to privacy, dignity and respect.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Links to any other associated documents

10 References

11 Appendices

11.1 Appendix A Resuscitation committee terms of reference

11.1.1 Name of committee or group

Resuscitation committee.

11.1.2 Purpose

The purpose of this resuscitation committee is to review the trust’s assurance processes for resuscitation and to oversee the annual audit work plan taking into account UK Resuscitation Council Quality Standards.

11.1.3 Membership

The membership of the group would include:

medical director (chair)
nurse consultant, St John’s Hospice (deputy chair)
lead learning and development facilitator, mandatory and statutory training
chief pharmacist or a nominated deputy
head of patient safety
clinical representation from each care group as determined by the relevant associate nurse director
medical representative
allied health professional representative
patient governor representative
non-executive director

11.1.4 Attendance

All members, or a nominated deputy, from each care group should attend each meeting. Each care group representative should have a clinical background. In addition, other directors, senior managers and advisors will be invited to attend as and when required. Attendance will be recorded in the minutes of each meeting.

11.1.5 Quoracy

The chair or deputy chair and a clinical representative from each care group should be present. The senior clinical representative will be determined by the associate nurse director from each care group.

11.1.6 Meeting arrangements (frequency, chair, venue, administrative support arrangements)

Meetings shall be held 3 monthly. Administrative support will be provided by the executive medical director’s personal assistant.

11.1.7 Key responsibilities or objectives or duties or powers

These key responsibilities (KR) will be represented in the agenda responsibilities of the resuscitation committee as defined by the Resuscitation Council (UK) include:

KR 1, ensuring implementation and adherence to national resuscitation guidelines and standards
KR 2, defining the role and composition of the resuscitation team
KR 3, ensuring that resuscitation equipment for clinical use is available and ready for use
KR 4, ensuring that appropriate resuscitation drugs (including those for peri-arrest situations) are available and ready for use
KR 5, planning adequate provision of training in resuscitation
KR 6, determining requirements for and choice of resuscitation training equipment
KR 7, preparing and implementing policies relating to resuscitation and treatment of anaphylaxis
KR 8, preparing and implementing policies relating to prevention of cardiac arrest
KR 9, preparing and implementing a policy on resuscitation decisions, (for example, DNACPR decisions), and advance care planning (this is usually in collaboration with palliative care teams)
KR 10, quality improvement, action plans based on audits, for example, review of audit data using National Cardiac Arrest Audit data for benchmarking
KR 11, recording and reporting of patient safety incidents in relation to resuscitation
KR 12, the resuscitation committee is responsible for implementing operational policies governing cardiopulmonary resuscitation, practice and training

An annual audit report will provide assurance against each of the above key responsibility areas and will include relevant audit data.

11.1.8 Receipt of minutes and reports from

Completed resuscitation audits and any other relevant clinical audits undertaken.

11.1.9 reporting arrangements

Quality Committee for assurance in relation to the key responsibilities outlined in section 7 via an annual resuscitation report.

Safety and quality operational group.

The Executive Management team for any issues that require an urgent executive operational response.

Involvement of a designated non-executive director will have oversight of, and will sit as part of, the resuscitation committee.

11.1.10 Date

Each year.

11.1.11 Review date

Each year.

11.1.12 Document owner or responsibility for review (lead director)

Executive medical director.

11.2 Appendix B The deteriorating patient HA

Appendix B The deteriorating patient HA (staff access only) (opens in new window)

11.2.1 Appendix B1 New head injury flow chart

Immediately perform an DRABC (danger, response, airway, breathing, circulation) assessment and assess for red flags (see list of red flags below).
Complete neuro observations, NEWS and full ABCDE assessment.
See neuro observation and NEWS2 chart guidelines (on reverse of the charts) for use.

If patient is breathing examine for injury, if none found, get patient up using appropriate techniques.

If injury found provide appropriate first aid.

11.2.1.1 If red flag signs or symptoms

If red flags signs or symptoms call 2222 or (9)999 for an emergency ambulance immediately.

Continue neuro observations and NEWS at least every 15 minutes until ambulance arrives, ensure SBAR handover ready for paramedic.
Paramedic to complete GCS arrival.

11.2.1.1.1 List of red flags

Unconsciousness or lack of full consciousness (post injury) for example, problems keeping eyes open.
Problems understanding, speaking, reading, or writing (post injury).
Loss of feeling in part of the body (post injury).
Problems balancing or walking (post injury).
General weakness (post injury).
Any changes in eyesight.
Any clear fluid running from ears or nose.
A black eye with no obvious damage around the eye.
Bleeding from one or both ears.
New deafness in one or both ears.
Bruising behind one or both ears.
Any evidence of scalp or skull damage, especially when the skull has been penetrated.
A forceful blow to the head at speed.
A seizure since the injury.
Amnesia for events before or after the injury (problems with memory) change from normal presentation.
Any vomiting episodes since the injury.
Any previous cranial neurosurgical interventions (brain surgery), history of bleeding or clotting disorder.
Current anticoagulant therapy (NICE (CG176) states for patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having anticoagulant treatment, perform a CT head scan within 8 hours of the injury (there will be times when this is not considered as clinically beneficial for the patient, for example, patient in the last days of life, a medical review and rationale for not performing a CT head must be documented)).
Current drug or alcohol intoxication.
Irritability or altered behaviour (easily distracted, not themselves, no concentration, no interest in things around them) change from normal presentation.

11.2.1.2 If no red flags but other changes

If no red flags but other changes (see list of other changes below)

11.2.1.2.1 Patient presentation

Must instigate call to clinician (usually a medical doctor but in some areas this function can be carried out by other designated clinical staff, for example, nurse consultants).
Request urgent visit.
Continue neuro observations and NEWS at least every 15 minutes until clinicians examination.

11.2.1.2.3 List of other changes

Any previous loss of consciousness (‘knocked out’) because of the injury, from which the injured person has now recovered.
Persistent headache since the injury.
Age 65 years or older.
Suspicion of non-accidental injury.
Continuing concern by the professional about the diagnosis or presentation.

11.2.1.2.4 If no red flags and no other changes

Continue neuro observations at least:

half hourly for 2 hrs
then hourly for 4 hrs
then 2 hourly until NEWS or neuro observations at baseline
must be reviewed by an appropriate clinician (NICE (CG176) states for patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having anticoagulant treatment, perform a CT head scan within 8 hours of the injury (there will be times when this is not considered as clinically beneficial for the patient, for example, patient in the last days of life, a medical review and rationale for not performing a CT head must be documented))
within 24 hours who will also complete GCS (on wards where GCS is part of existing practice GCS to be completed by ward staff)
if neuro observations and NEWS are as baseline at initial reading continue observations for at least 6 hrs post event

Continue to monitor for red flags (as these can take longer to present).

Any new signs or symptoms should be escalated immediately.

11.2.2 Appendix B2 Ligature flow chart

Ligature found around a patient’s neck, call for help (use walkie talkie or activate alarm if available).
Request emergency equipment and ligature cutter.
Assess, approach patient from the front when safe to do so.

11.2.2.1 Suspected strangulation

11.2.2.1.1 Complete, body suspended by ligature from a fixed point

Hold patient at thighs or hips and raise slightly to reduce tension on ligature.
After tension on ligature is reduced and with assistance to support weight of patient, safely remove or cut ligature between anchor point and knot. Lay patient supine and cut ligature from neck.
Qualified nurse to assess, perform DRABC assessment, assess for “RED FLAGS” (see list of red flags below) and undertake full set of neuro observations and NEWS2. Protect c-spine and use jaw thrust to open airway if airway is compromised.

11.2.2.1.2 Incomplete, body is not suspended entirely via a ligature

Hold patient at torso and raise slightly to reduce tension on ligature.
After tension on ligature is reduced and with assistance to support weight of patient, safely remove or cut ligature between anchor point and knot. Lay patient supine and cut ligature from neck.
Qualified nurse to assess, perform DRABC assessment, assess for “RED FLAGS” (see list of red flags below) and undertake full set of neuro observations and NEWS2. Protect c-spine and use jaw thrust to open airway if airway is compromised.

11.2.2.2 Lying strangulation (body is on the floor at low level anchor point)

Slide patient up towards ligature to reduce tension and safely remove or cut ligature.

Qualified nurse to assess, perform DRABC assessment, assess for “RED FLAGS” (see list of red flags below) and undertake full set of neuro observations and NEWS2. Protect c-spine and use jaw thrust to open airway if airway is compromised.

11.2.2.3 Unsuspended strangulation

If torso is not under any ligature pressure, continue to safely remove or cut ligature.

11.2.2.4 Red flags

Resuscitation required.
Suspected neck fracture.
Difficulty or painful swallowing.
Crepitus or subcutaneous crepitus (air under skin with crackling or crunchy feeling to touch).
Tenderness over hyoid bone.
Any loss of consciousness.
Deeply indented ligature mark.
A long period of ligature Cyanosis (blue lips and skin) not subsiding immediately after ligature removal.
Sweating or clamminess.
Continued coughing.
Petechial haemorrhages (small red marks with pinpoint centres on eyes, face, neck or lips).
Suffocation when sticking out tongue.
Persistent breathlessness or hoarseness since ligature incident.

Call ambulance for transfer to accident and emergency or emergency department or urgent and emergency care centre

11.2.2.5 No red flags

11.2.2.5.1 NEWS2 above baseline or any other concern

Call doctor or other designated clinician (ANP, ACP, physician associate).

Clinician review within 2 hours to undertake history and physical examination including assessment of:

patency of airway
breathing
swallowing
neurological system

Reassess for red flags. Review frequency and duration of ongoing physical observations

11.2.2.5.2 NEWS2 at baseline and no other concerns

Monitor:

neuro observations and NEWS2
every 15 minutes for 1 hour
every 20 minutes for next
3 hours (minimum)

Over next 36 hours, be alert for the emergence of:

confusion
sweating
tender larynx
mild cough
wheezing hypoxia
Swelling of the neck
rapid breathing or shortness of breath
muffled or hoarse voice
fast and, or irregular pulse rate
motor or sensory loss

Seek medical review if signs emerge or as indicated by NEWS2 or neuro observations.

11.6 Appendix F Young people aged 16 and 17 years special considerations

Some special considerations apply where patients are aged 16 or 17 years.

11.6.1 Current practice relating to young persons

The Association for Children’s Palliative Care (2004) recommends that every young person with a life limiting condition should be helped, with their family, to decide on an end of life or palliative care plan.

Within RDASH, the large majority of children (16 to 18 years) needing palliative care are under specialists in Sheffield.

11.6.2 Who should or could initiate discussion, and when?

It can be appropriate for professionals looking after young people with life limiting or life threatening conditions to initiate discussion about end of life planning well before the young person is terminally ill. It may also be appropriate to begin discussions if a young person has an acute illness or repeated illness as a result of which it becomes clearer to professionals and, or the parents that the young person is moving into a terminal phase of their illness, or that they are at an increased risk of a more sudden life threatening illness or event. Usually the most appropriate professional to initiate this discussion is the named paediatrician or palliative care practitioner.

If professionals initiate discussion, consideration should be given to the sensitive timing of this and further support for the family and young person may be necessary. Decision-making should not be forced on a young person or family. If a professional initiates a discussion about do not attempt cardio pulmonary resuscitation (DNACPR) and the young person or family indicate they do not wish to continue, their wishes should be respected, and the details recorded in the young person’s medical record.

Discussion may also be initiated by the young person or family at any time.

11.6.3 Who can make decisions?

The Department of Health (2009) state that:

‘by virtue of section 8 of the Family Law Reform Act 1969, young people aged 16 and 17 are presumed to be capable of consenting to their own medical treatment. As for adults, consent will be valid only if it is given voluntarily by an appropriately informed young person capable of consenting to the particular intervention. However, unlike adults, the refusal of a competent person aged 16 to 17 may in certain circumstances be overridden by either a person with parental responsibility or a court’

In exceptional circumstances it may be impossible for all concerned to reach a united decision regarding the best interest of the young person. If this cannot be resolved by the patient’s consultant, the consultant should request further advice from regional experts, trust medical director and trust legal services department.

To establish whether a young person aged 16 or 17 has the requisite capacity to consent to the proposed intervention, the same criteria should be used as for adults. If a young person lacks capacity to consent because of an impairment of, or a disturbance in the functioning of, the mind or brain then the Mental Capacity Act (2005) will apply in the same way as it does to those who are 18 and over (Department of Health (2009)).

Where a young person lacks capacity to decide, a person with parental responsibility for the young person may make a DNACPR decision where they consider that to be in the young person’s best interests.

If a 16 or 17 year-old is capable of making an informed decision then it is not legally necessary to obtain additional consent from a person with parental responsibility. It is, however, good practice to involve the young person’s family in the decision-making process, unless the young person specifically wishes to exclude them, if the young person consents to their information being shared.

If a young person decides that he or she does not wish to be resuscitated and that the family should not be involved with or informed about the decision this must be urgently referred to the trust medical director and legal services department.

11.6.4 What is, and who has, parental responsibility?

Parental responsibility is defined by section 3 of the 1989 Children Act as “all rights, duties, powers, responsibilities and authority which by law a parent of a child has in relation to a child and his property”. Parental responsibility is therefore concerned with bringing the child up, caring for him and making decisions about him, including the right to consent or withhold consent for medical treatment. Parental responsibility is relinquished on a young person’s eighteenth birthday.

The Children Act 1989 sets out persons who may have parental responsibility. These include:

the child’s mother
the child’s father, if he was married to the mother at the time of birth
unmarried fathers, who can acquire parental responsibility in several different ways:
- for children born before 1 December 2003, unmarried fathers will have parental responsibility if they:
  - marry the mother of their child or obtain a parental responsibility order from the court
  - register a parental responsibility agreement with the court or by an application to court
- for children born after 1 December 2003, unmarried fathers will have parental responsibility if they:
  - register the child’s birth jointly with the mother at the time of birth
  - re-register the birth if they are the natural father
  - marry the mother of their child or obtain a parental responsibility order from the court
  - register with the court for parental responsibility
  - the child’s legally appointed guardian
  - a person in whose favour the court has made a residence order concerning the child
  - a local authority designated in a care order in respect of the child
  - a local authority or other authorised person who holds an emergency protection order in respect of the child.
- it should be noted that:
  - if a child is in local authority care parents can share parent responsibility with the local authority, this is lost if the child is adopted
  - parental responsibility can also be restricted by a court order
  - foster parents do not automatically have parental responsibility

11.6.5 Children in local authority care

Where a child is in the care of the local authority the child’s social worker must be involved in all of the discussions as well as parents, as the local authority shares parental responsibility with the parents. However, when a child is in voluntary care (section 20, Children Act 1989) the parents retain full parental responsibility.

11.6.5.1 What happens when a young person and a person with parental responsibility disagree about a DNACPR decision?

Decision-making with young people may be a matter of negotiation between the child, those with parental responsibility and clinicians. Inevitably there will be times when young people and those with parental responsibility for them do not agree about whether a DNACPR decision should be made.

If a young person is deemed to have the capacity to make a DNACPR decision (or believes he or she has capacity to make a decision?) and there is disagreement between the patient and those with parental responsibility despite attempts to reach agreement, legal advice should be sought.

What happens when medical staff and a young person or persons with parental responsibility disagree about a DNACPR decision?

Where medical staff are strongly of the opinion that cardiopulmonary resuscitation should not be attempted but the young person or people with parental responsibility disagree, or vice versa, a legal opinion should be sought.

11.6.6 Safeguarding issues

Where there is doubt about whether a person with parental responsibility is acting in the interest of the young person, then local safeguarding children board procedures must be instigated.

11.6.7 Education establishments

Potentially a young person may wish to continue at school with an agreed DNACPR decision in place. This can potentially cause anxieties for both the family and staff supporting that young person. Advice can be sought from a palliative care practitioner in dealing with those anxieties and what measures can be put in place to support the child and family during this period.

11.6.8 Interface with the child death overview process

Each safeguarding board has a designated paediatrician for all unexpected child deaths who are supported by a Rapid Response team. All deaths of a person under 18 years of age must be reported to the rapid response professional in the local area, who will notify the child death overview panel of the local safeguarding children board in accordance with the statutory guidance in chapter 7, Working Together to Safeguard Children 2010. DNACPR status must be reported at this time. The rapid response team contact details can be found on the local safeguarding children’s board website.

11.7 Appendix G Cardio-pulmonary resuscitation decision-making framework HA

Is cardiac or respiratory arrest a clear possibility?
- no, it is not necessary to discuss CPR with the patient unless they express a wish to discuss it
Yes, is there a realistic change that CPR could be successful?
- no, if a DNACPR decision is made on clear clinical grounds that CPR would not be successful there should be a presumption in favour of informing the patient of the decision and explaining the reason for it (see section 5). Subject to appropriate respect for confidentiality those close to the patient should also be informed and offered an explanation
- where the patient lacks capacity and has a welfare attorney or court-appointed deputy or guardian, this representative should be informed of the decision not to attempt CPR and the reasons for it as part of the ongoing discussion about the patient’s re (see section 5)
- if the decision is not accepted by the patient, their representative or those close to them, a second opinion should be offered
Yes, does the patient lack capacity and have an advance decision specifically refusing CPR or have an appointed attorney, deputy or guardian?
- yes, if a patient has made an advance decision refusing CPR, and the criteria for applicability and validity are met, this must be respected.
- if an attorney, deputy or guardian has been appointed they should be consulted (see sections 9.1 and 10)
No, does the patient lack capacity?
- yes, discussion with those close to the patient must be used to guide a decision in the patient’s best interests (see section 10). When the patient is a child or young person, those with parental responsibility should be involved in the decision where appropriate, unless the child objects (see section 11)
No, is the patient willing to discuss his or her wishes regarding CPR?
- no, respect and document their wishes (see section 6.3). Discussion with those close to the patient may be used to guide a decision in the patient’s best interests, unless confidentiality restrictions prevent this
Yes, the patient must be involved in deciding whether CPR will be attempted in event of cardiorespiratory arrest.

If cardiorespiratory arrest occurs in the absence of a recorded decision there should be an initial presumption in favour of attempting CPR.
Anticipatory decisions about CPR are an important part of high-quality health care for people at risk of death or cardiorespiratory arrest.
Decisions about CPR are sensitive and complex and should be undertaken by experienced members of the healthcare team with appropriate competence.
Decision about CPR require sensitive and effective communication with patients and those close to patient.
Decision about CPR must be documented fully and carefully.
Decisions should be review with appropriate frequency and when circumstances change.
Advice should be sought if there is uncertainty.

Taken from Resuscitation Council UK, British Medical Association and Royal College of Nursing (2016) Decisions relating to cardiopulmonary resuscitation. 3rd. (opens in new window) (accessed 9 June 22)

11.8 Appendix H Do not attempt cardiopulmonary resuscitation form (WZT652)

Appendix H Do not attempt cardiopulmonary resuscitation form (WZT652) (staff access only) (opens in new window)

11.9 Appendix I Do not attempt cardiopulmonary resuscitation communication sticker

Appendix I Do not attempt cardiopulmonary resuscitation communication sticker (staff access only) (opens in new window)

11.10 Appendix J What if my heart stops leaflet

Appendix J What if my heart stops leaflet

11.11 Appendix K Where to document the DNACPR decision in the electronic records

Search for DNACPR in templates or locate RDaSH DNACPR in the left-hand clinical tree under corporate templates.
Right click on RDaSH DNACPR.
Click again on RDaSH DNACPR.
The green information box will come up.
Click the grey DNACPR tab at the top.
This page gives a guide to DNACPR. The grey tab goes to the page to be completed, see next page.
Tick the relevant boxes.
Select the correct action from the drop-down menu, for example, not for attempted CPR.
Write the details of the conversation with the patient or those closest to them, or the review on an existing document in the ‘detail of information’ box.
If having a review date, tick the box.
If valid until the end of life, tick the box.
Press OK and Save as normal.

11.12 Appendix L Do not attempt cardiopulmonary resuscitation child under 16 letter

Appendix L Do not attempt cardiopulmonary resuscitation child under 16 letter (staff access only) (opens in new window)

Document control

Version: 1.1.
Unique reference number: 1011.
Approved by: Clinical policies review and approval group.
Date approved: 20 February 2024.
Name of originator or author: Dr Graeme Tosh, Medical Director and Resuscitation Committee Chair, Heidi Atkinson, Nurse Consultant in Palliative Care and Resuscitation Committee Deputy Chair, Millie Soley Resuscitation Officer.
Name of responsible committee or individual: To be confirmed.
Date issued: 27 February 2024.
Target audience: All staff.

Page last reviewed: November 14, 2024
Next review due: November 14, 2025

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