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Key changes and clarifications for version 4 (2020)

  • Expansion on the concept of ‘Natural Anticipated and Accepted Death’ (NAAD) as a trigger to consider a DNACPR discussion and decision
  • DNACPR/CPR discussions with patients should be offered, especially if it is felt that talking about death and dying may be harmful
  • Reiteration that blanket approaches to DNACPR are never acceptable and each decision must be highly individualised to the person affected
  • Decisions regarding CPR are a major healthcare decision and should be given appropriate respect and priority
  • Clarification on who can hold discussions and who can sign section 5 of the DNACPR form, including nurses, junior doctors and from 2020 onwards, AHPs like paramedics
  • Everyone who is involved in DNACPR decisions and forms should have read the All Wales policy document
  • Rather than tasking patients and their loved ones with a decision on whether they would want CPR or not, convey the views of the healthcare professional (and team) why a DNACPR decision is necessary, and how low the success rates of CPR can be - this may involve several conversations outlined by the Royal College of Physicians’ ‘Talking about Dying Report 2018’
  • A reminder of other existing forms relating to Advance and Future Care Planning, including legally binding Advance Decisions to Refuse Treatment, which are filled in by patients to specify their refusals and location of All Wales versions of the forms and guidance
  • There is now a simpler URL to house the policy:  www.wales.nhs.uk/DNACPR
  • To clarify that patients, contrary to occasional media reports on this issue, are never asked to physically sign DNACPR forms themselves - the form has healthcare professional signatories
  • Once a decision has been reached, to offer each individual and/or their proxy a copy of their DNACPR form to ensure it is with them and can be shown to visiting healthcare professionals in future
  • The policy reiterates that a DNACPR form does not preclude people from all other treatments that may still be appropriate - patients for instance still receive ongoing chemotherapy or other treatments that may help reverse potentially reversible problems
  • Legal updates including distress versus harm when assessing risks of discussing ceilings of treatments/CPR with patients and their proxy
  • Concept of ‘shared understanding’ in the context of CPR and DNACPR
  • Cross-border forms including ReSPECT from England, and DNACPR forms from Scotland and their application in clinical settings in Wales
  • Need for Senior Responsible Clinician, usually a GP or circumstances a senior nurse or associate specialist in charge of an inpatient unit to sign form in section 6
  • Clarification that when a senior responsible clinician cannot personally sign the form at a specific time they can be communicated with remotely and where they agree with a DNACPR decision, this can be noted in section 6 of the form - this can be important in situations where clinicians cannot easily get to a care home or setting where individuals are isolating or quarantining, but still keeps the Senior Responsible Clinicians involved and referenced on the form
  • Where the Welsh language version of the form is preferred, an English language copy must be appended to ensure that any healthcare professionals not proficient in Welsh can understand all the important content of the form in an emergency
  • If the person moves from one place to another (for example, to or from home, hospital, hospice, care home, or from one hospital ward to another) it is good practice to review the DNACPR form, to ensure that its recommendations remain valid, but a new form will not automatically be needed (for instance to change the home address to the hospice or care home address) unless the clinical recommendations change
  • Further information on the Message in a Green Bottle Scheme to help Welsh Ambulance Service and healthcare staff visiting someone’s home to be alerted to important documentation
  • Advice on offering second opinions when CPR is expected by patients
  • Updated guidance on DNACPR in the context of Implantable Cardioverter Defibrillator Devices (ICDs) from the Welsh Cardiac Network
  • Updates on situations when there is no DNACPR form or other Advance and Future Care Plan such as an ADRT in place, and the clinician attending is as clear as they can be that the person is dying or has already died: the regulating organisations (GMC, NMC and HCPC) have issued individual guidance that CPR does not have to be automatically given on scene by default
  • Training on DNACPR including ESR resources
  • Audit of DNACPR processes
  • Update of Reference list, including legal cases and guidance from GMC, NMC at others
  • A request on the DNACPR form itself to write in the free-text sections to briefly describe the conversation that has been held