Version: / 2
Written by: / Eithne Ni Dhomhnaill and Andrea O’ Reilly, Nursing Matters and Associates.
Adapted for local use by:
Issue Date: / October 2012
Review date: / October 2014
Authorised by:
1.0Policy Statement:
It is the policy of the Centrethat decisions regarding emergency care and treatment including cardiopulmonary resuscitation (CPR) and / or transfer to hospital will be made on the basis of an individual assessment of each resident. Such decisions will be made in accordance with the requirements for informed consent with the resident and /or his/her representative. In the event that a resident is in cardiac and / respiratory arrest cardio-pulmonary resuscitation will be given unless there is a clear entry in the resident’s medical notes to the contrary.
2.0Purpose:
The purpose of this policy is to outline the decision-making process and procedures for cardio-pulmonary resuscitation in the Centre.
3.0Objectives:
3.1To ensure that decisions regarding cardio-pulmonary resuscitation are made on the basis of individual assessment of the needs and wishes of each resident in accordance with the requirements for informed consent.
3.2To outline the procedure for cardio-pulmonary resuscitation. (CPR).
3.3To outline the procedure for Automated External Defibrillation (AED)
4.0Scope:
This policy applies to all health care professionals involved in making decisions about emergency and advanced care and treatment for a resident.A decision not to attempt CPR applies only to CPR. It does not apply to any other aspect of treatment and all other treatments and care that are appropriate for the service user should continue.
5.0Definitions:
5.1Advance care planning: Refers to a process of discussion between a service user, his/her care providers, and oftenthose close to them, about future care. Advanced care planning usually takes place in thecontext of an anticipated deterioration in the service user’s condition in the future, withattendant loss of capacity to make decisions and/or ability to communicate wishes toothers. Issues which may be discussed are the service user’s concerns, his/her values orpersonal goals for care, his/her understanding of their illness or prognosis, in addition toparticular preferences for types of care or treatment and preferred place of care in thefuture. - [Hospice Friendly Hospitals (2010).
5.2Advance healthcare directive: An advance healthcare directive is a statement made by a competent adult relating to the type and extent of medical treatments he/she would or would not want to undergo in the future if unable to express consent or dissent at that time. (Health Services Executive, 2012)
5.3Cardiac arrest – the sudden, unexpected cessation of the heartbeat and effective circulation. There is an immediate loss of consciousness, an absence of pulses, signs of circulation and breathing (Brunner & Suddarth, 1992).
5.4Ventricular Fibrillation – a rapid ineffective quivering of the ventricles. There is an absence of an audible heartbeat, no pulses or breathing present (Brunner & Suddarth, 1992).
5.5Cardiopulmonary resuscitation (CPR) - An attempt to restore spontaneous circulation by using chest wall compressions and pulmonary ventilations (American Heart Association 2001).
5.6Cardiac arrest: Cardiac arrest is the cessation of cardiac contraction.
5.7Respiratory arrest is the cessation of effective oxygenation and ventilation.
5.8Cardiorespiratory arrest is a combination of cardiac and respiratory arrest.
5.9Automated External Defibrillator (AED) – a computer device used to defibrillate victims within a few minutes of collapse due to ventricular fibrillation (American Heart Association 2001).
5.10Foreign body airway obstruction (FBAO) – an occlusion of the airway due to a foreign body. The victim will be unable to speak, breathe or cough forcefully and may clutch their neck with the thumb and fingers, making the universal choking sign. Movement of air is absent (American Heart Association 2001).
5.11Do Not Attempt Resuscitate (DNAR) Order:A do not attempt resuscitation (DNAR) order is a written order stating that resuscitation should not be attempted if a service user suffers a cardiac or respiratory arrest. A DNAR order may be instituted on the basis of the resident’s clearly expressed wishes. Also a DNAR order may be made following a clinical evaluation of the likely benefit of attempted CPR for a resident (HSE, 2012).
5.12Family: In this policy, family may include the immediate biological family and/or other relatives, spouses, partners (including same sex and de facto partners) or friends. They may have a close, ongoing, personal relationship with the service user, be chosen by the service user to be involved in treatment decisions, and have themselves indicated that they are ready to be involved in such decisions (HSE, 2012).
6.0Responsibility Matrix.
Actions / Responsible Person (s)All new staff will be given an explanation of this policy and CPR/AED training on induction. / Person in Charge/Director of Nursing.
A record of all staff who have signed that they have both read and understood these policy document will be kept. / Person in Charge/Director of Nursing.
This policy will be reviewed 2 years from the date of implementation or earlier if changes to national policy/strategies indicate an earlier review date. / Person in Charge/Director of Nursing.
All staff will have the required CPR and AED training to provide the care outlined in this policy. / Person in Charge/Director of Nursing.
All nursing and care staff must attend CPR and AED training and are responsible for updating their training every second year. / All nursing and care staff.
Periodic assessment of staffs knowledge and skills, with reinforcement or refresherinformation should be provided as needed (not just formal training every 2 years) / Person in Charge/Director of Nursing.
Nurses will maintain their competence and communicate any knowledge deficits / education needs. / All registered nurses.
All nursing staff have a responsibility to read the resuscitation policy in accordance with the Scope of Practice Framework and sign the policy acknowledgement form. / All registered nurses.
Decisions regarding resuscitation will be in accordance with this policy. / All healthcare staff involved in decision-making regarding resuscitation.
Emergency equipment (mask, airway, suction and Oxygen etc) and AED must be checked and documented once per week. This involves checking that the contents are correct, and clarifying that all emergency equipment is working correctly. / Designated clinical staff member.
Discussions relating to decisions about resuscitation and the subsequent decisions will be documented in the resident’s medical notes. / Residents’ General Practitioners.
Nursing staff must also re-stock and check the emergency equipment after use in any resuscitation. / Nurses on duty during cardio-pulmonary resuscitation intervention.
Debriefing should occur following cpr to facilitate learning and should be used to review performance in the Centre to improve subsequent performance. / Person in Charge/Director of Nursing.
7.0Protocol for Making Decisions about Cardio-Pulmonary Resuscitation and DNAR Orders.
7.1Timing of Decision Making for CPR and DNAR orders.
7.1.1As part of the comprehensive nursing assessment, every resident is asked about preferences or wishes they may have in the event of deterioration of their condition.
7.1.2Discussions about CPR and DNAR orders may take place as part of advanced care planning for a resident, however, it may not be necessary to initiate a discussion about CPR with a resident if there is no reason to believe that he/she is likely to suffer a cardio respiratory arrest.
7.1.3Initiating discussions regarding CPR and DNAR will depend on the overall condition of each residentand the likelihood of cardiorespiratory arrest occurring.
7.1.4For residents where cardio respiratory arrest is considered unlikely,the general presumption in favour of CPR should operate in the unlikely event of an arrest (HSE, 2012). However, if the resident indicates that he/she wishes to discuss CPR, then thisshould be respected.
7.1.5For residents who are at the advanced stages of a life limiting condition, where death is considered to be imminent and unavoidable and cardiorespiratory arrest may represent the terminal event in their illness, the provision of CPR would not be clinically indicated. In these cases, discussion about end-of-life care needs and preferences will be undertaken with the resident and / or representative. The resident’s GP, palliative care team or hospital teamif involved will undertake these discussions. However, this does not necessarily require explicit discussion of CPR or an ‘offer’ of CPR.
7.1.6A DNAR order for those close to death does not equate to “doing nothing”; care provided should follow a palliative approach and focus on easing that resident’s suffering and attending to their comfort needs.
7.1.7For some residents, cardiorespiratory arrest may be considered possible or likely as a result of their clinical condition.For these residents, consideration of issues such as CPR/DNAR should occur in the context of a general discussion about their prognosis as well as his/her values, concerns, expectations and goals of care.
7.2Persons Involved in Decision Making.
7.2.1Decisions regarding CPR and DNAR orders will involve the resident as far as he/she is able and will be made in the context of the resident’s overall goals and preferences for his/her treatment and care.If the resident has capacity, the involvement ofothers in decision making, such as a relative, partner or friend, will be based on the resident’s wishes and his her informed consent.
7.2.2If the resident is unable to participate in discussions due to his/her physical or cognitivecondition, those with a close, on-going, personal relationship with the resident may be included in discussions so as to gain insight into the resident’s previously expressed preferences, wishes and beliefs.The role ofthose close to the service user is not to make the final decision regarding CPR, but rather tohelp the healthcare team to make the most appropriate decision.
7.2.3Decision making regarding CPR and DNAR will also involve the views and observations of the person in charge and the nursing team.
As a general rule, if no advance decision not to perform CPR has been made, and the wishes of the service user are unknown and cannot be ascertained, there is a presumption in favour of providing CPR, and healthcare professionals should make all appropriate efforts to resuscitate the service user. In these circumstances, the extent and/or duration of the CPR attempt should be based on the clinical circumstances of the arrest, the progress of the resuscitation attempt and balancing the burdens and benefits of continuing CPR.
National Consent Advisory Group, 2012.
7.3AssessingCapacity for Decision Making.
7.3.1Each resident is presumed to have the capacity to make decisions, unless there is reason to consider incapacity.
7.3.2Capacity is judged in relation to the particular decision to be made, at the time it is to be made.
7.3.3Capacity depends on the ability of the resident to comprehend, reason with andexpress a choice with regard to information about a specific treatment (e.g. the benefits and risks involved or the implications of not receiving the treatment).
7.3.4The possibility of incapacity and the need to assess capacity formally is considered, if, having been given all appropriate help and support, a resident:
Is unable to communicate a clear and consistent choice;
Is obviously unable to understand the information and choices provided; or
Makes a choice that seems to be based on a misperception of reality or one thatdoesn’tseem consistent with that person’s known beliefs and values insofar as they are known.
7.3.5Capacity to consent will be assessed if there is sufficient reason to question the presumption of capacity. This involves assessing whether:
The resident understands in broad terms the reasons for and nature of the decision to be made.
The resident has sufficient understanding of the principal benefits and risks of an intervention and relevant alternative options after these have been explained to them in a manner and in a language appropriate to their individual level of cognitive functioning.
The resident understands the relevance of the decision, appreciates the advantages and disadvantages in relation to the choices open to them and is able to retain this knowledge long enough to make a voluntary choice.
7.3.6Where a resident lacks capacity, discussions will also consider the resident’s medical history, previously expressed or known wishes / preferences and expected outcomes of providing CPR to the resident.
7.3.7Consideration of the risks, burdens and benefits are included in discussions about CPR.In particular, discussions will focus on whether the benefits would outweigh the risks andburdens for the resident. Agreement will be made between the healthcare team and those close to the resident.
7.3.8Only relevant informationshould be shared with those close to a resident unless, when he/she was previouslycompetent expressed a wish that information be withheld.
7.4Provision of Information to Residents.
7.4.1The resident should be given enough information and in a format that he / she can understand in order to support decision making and ensure valid, informed consent. This includes the following information:
Their diagnosis and prognosis including any uncertainties about the diagnosis or prognosis.
Options for treating or managing the condition, including the option not to treat.
The purpose of any proposed intervention and what it will involve.
The potential benefits, risks and the likelihood of success of a proposed intervention, as well as that of any available alternative.
7.4.2When providing information to a resident to aid decision making, the following should be adhered to:
Discussions about treatment options should be carried out in a place and at a time when the resident is best able to understand and retain the information.
The resident should be provided with adequate time and support, including, if necessary, repeating information.
Simple, clear and concise English should be used and avoidance of medical terminology.
Written or verbal information should be supplemented with visual depictions if required.
The resident should be asked if there is anything that would help them remember information, or make it easier to make a decision; such as bringing a relative, partner, friend, carer or advocate to consultations.
Discussions should take cognisance of the resident’s individual needs and preferences for communication.
7.4.3Where a resident consistently refuses to discuss CPR/DNARorders, this should be respected and documented in the resident’s medical notes. The ultimate decision whether or not CPRwould be in the resident’s best interests rests with the resident’s doctor and upon consideration of the clinical informationavailable.
7.4.4Where a resident refuses CPR, this should be respected and for resident’s who have previously prepared an advanced directive refusing CPR in certain circumstances, this should also be respected provided the directive is considered valid and applicable tothe situation that has arisen.
7.5Balancing Risks and Burdens of CPR.
7.5.1The decision to use CPR should be based on the balance of burdens, risks and benefits to the resident as well as his/her own preferences and values. When discussing CPR with a resident, the resident’s doctor will ensure that the resident understands the relevant benefits and burdens.
7.5.2When the balance between risk and benefit is uncertain, the resident’s doctor will acknowledge the uncertainty and outline the benefits and risks of each option and assist the service user in coming to a decision.
7.5.3In situations where attempting CPR is considered to have a reasonable chance of successfully restarting the heart and breathing and the resident has decided that the quality of life that can reasonably be expected would be acceptable then his/her wishes should be respected.
7.5.4In some circumstances, the resident’s doctor may judge that the risks and burdensassociated with CPR outweigh the potential benefits and that a DNAR order should be put inplace. In these situations, the resident’s doctor will explain the reasons behind this judgement, including anyuncertainty, to recommend that a DNAR order should be written, and to seek the views ofthe resident in this regard.
7.5.5When there is disagreement about the balance of benefits and burdens from CPRan offer of a second, independent opinion can bemade. Where all previous efforts at resolution have proven unsuccessful it may benecessary for parties to consider obtaining legal advice. The same procedure should becarried out if those close to a service user who lacks capacity do not accept a DNAR decision.
7.6Record Keeping.
7.6.1Outcomes of discussions regarding CPR and DNAR orders must be documented in the resident’s medical notes.
7.6.2The record of discussions should include the involvement of the residents and / or others who were involved in the discussions.
7.7A review of decisions regarding CPR must undertaken where there is a significant change in the resident’s care and / or condition and in situations where a resident is undergoing a surgical procedure because of the potential for cardio respiratory arrest during anaesthesia.
7.8In certain situations, a resident with a DNAR order may suffer a cardiorespiratory arrest from a readily reversible cause unconnected to his/her underlying illness. In such cases CPR would be appropriate, while the reversible cause of arrest is treated. For example, choking restricts an individual’s intake of oxygen, which could potentially lead to a cardiorespiratory arrest if not treated promptly. The initial response should concentrate on removing the cause of the tracheal blockage, but in the event of a subsequent cardiorespiratory arrest, CPR should be provided.
National Consent Advisory Group, 2012.
8.0Quick Reference Guide for CPR.
9.0American Heart Association Adult Chain of Survival
- Immediate recognition of cardiacarrest and activation of theemergency response system.
- Early CPR with an emphasis onchest compressions.
- Rapid defibrillation.
- Effective advanced life support.
- Integrated post–cardiac arrest care.
10.0Cardiac Arrest Procedure.