1. Introduction
Coast Medic is committed to providing all patients with the best care possible in accordance with best practice guidelines, procedures and protocols.
2. Aims and Objectives
This Policy is relevant to all patients to whom Coast Medic attend who have a valid DNAR or any other official advanced documentation in place, and includes those patients being transferred from a hospital or hospice to a preferred place of care. It must be used in conjunction with the companies Consent and Capacity Policy which includes details regarding Advanced Directives of Refusal of Treatment and the current JRCALC Recognition of Life Extinct (ROLE) guideline.
In October 2007 The British Medical Association, The Resuscitation Council (UK) and the Royal College of Nursing published a document entitled “Decisions relating to cardiopulmonary resuscitation” which deals specifically with DNAR orders. Within this document it states that “procedures must be in place to notify the ambulance staff of the patients CPR status, and provide them with the necessary documentation, before the journey commences”.
Ambulance clinicians, during the management and transportation of patients, have a responsibility for the continuation of patient care. This would include care for those patients with valid DNAR decisions if they have been put in place by a responsible clinician, prior to the transfer of a patient.
It must be understood that the company cannot make DNAR decisions.
DNAR decisions will have been made following, where appropriate, discussion and consultation with the patient and in most cases with consideration of the views of the patients family/next of kin. This process will have taken place following full consideration of the patient’s condition and based on set standards. It is the responsible clinician’s duty to ensure these standards are adhered to.
3. Definitions
ADRT – Advanced Directives of Refusal of Treatment – a patient’s document which refuses specific treatments, which commonly (but not always) includes CPR. It is specific to a defined situation.
Cardiopulmonary Arrest – The sudden and complete loss of cardiac and pulmonary function.
CPD – Continued professional development.
CPR – Cardiopulmonary Resuscitation.
DNAR – Do Not Attempt Resuscitation; an order agreed within a health care delivery setting which informs health and social care professionals not to resuscitate the patient.
EDC – Emergency Dispatch Centre.
JRCALC – Joint Royal Colleges Ambulance Liaison Committee.
PTSDC – Patient Transport Service Dispatch Centre.
Respiratory Arrest – The complete loss of respiratory function.
Responsible Clinician – See Appendix A.
Resuscitation – The act of reviving or condition of being revived.
RMCGC – Risk Management & Clinical Governance Committee.
ROLE – Recognition of Life Extinct.
4. Policy Statement
This policy is intended to implement a standard response by all clinicians when dealing with patients who have a Do Not Attempt Resuscitation (DNAR) or other advanced paperwork orders in place.
5. Arrangements
Delivery of education and training to ambulance clinicians responsible for dealing with patients who have a valid DNAR order in place will be in accordance with current JRCALC guidance and in conjunction with the Consent and Capacity policy.
The schedule of education and training will be determined through the Training Needs Analysis, and agreed with the Education and Training department, where it will form part of Statutory and Mandatory Training for all clinical staff.
All requests to transport patients with valid DNAR orders will be processed as per the Booking & Planning Policy and algorithm.
The ambulance clinician assigned to the patient will assess and manage the patient in accordance with current JRCALC guidance.
Resuscitation of the patient will be carried out as required unless a valid DNAR is in place or the patient meets the criteria for ROLE procedure or an Advanced Decision to Refuse Treatment which includes refusal of CPR is in place.
The DNAR order if valid, is relevant regardless of the reason for the death. It should not be confused with an ADRT, which is specific to the context to which it refers. For example, an ADRT may be present which clearly refers to artificial resuscitation in the event of a worsening chest infection in a patient with COPD. This would not however, preclude treatment if the patient chokes on a food bolus.
The clinician must check for DNAR paperwork as soon as possible after arrival at the patient’s location and ensure that it is currently valid and signed by the responsible clinician in charge of the patient’s care, e.g. the Consultant, or General Practitioner or senior nurse or specialist registrar. Photocopies are only acceptable if the responsible clinician has actually signed the photocopy in ink.
If there is doubt about the validity of the DNAR or if the clinician is unsure whether ROLE criteria is met resuscitation must be commenced until validation is obtained.
With the exception of CPR, if indicated, all other care and treatments must be carried out as normal. DNAR decisions apply only to CPR and not any other aspects of treatment unless specified explicity in any other official forms of advanced directives.
Where the expected benefit of attempted CPR may be outweighed by the burdens, the patient’s informed views are of paramount importance. If the patient lacks capacity, those close to the patient should be involved in discussions to explore the patient’s wishes, feelings, beliefs and values. They may, however, not make the decision on the patient’s behalf unless they have the authority of a lasting power of attorney registered with the Public Guardian which specifically includes health and welfare and includes refusal of resuscitation.
If the patient has a time critical condition and there is any uncertainty, resuscitation should not be delayed.
For arrangements regarding consent and capacity refer to the Consent and Capacity policy and procedures.
6. Responsibilities
The company directors retains overall responsibility for this policy.
The Operations Manager will be responsible for ensuring that the training and education provided is matched to the requirements and role of the clinician concerned. This will be based on the job description and clinical profile of the role. The training will be delivered to ensure competency in areas of DNAR procedures. The induction process will ensure that training is made available to all staff involved in resuscitation and DNAR procedures and that they will reflect any changes or developments in clinical practice with notifications and annual refreshers.
The Medical Director will be responsible for the monitoring and implementation of any national changes to clinical practice, e.g. National Institute for Health and Clinical Excellence or JRCALC. This will be undertaken by the Manager responsible for Clinical Governance within Coast Medic.
All staff are responsible for ensuring they are competent in the latest DNAR, ADRT, advance directives and ROLE procedures as part of their continued professional development (CPD).
The Operations manager will be responsible for maintaining up to date training records for all staff in relation to DNAR procedures. All staff will be responsible to ensuring they are competent and up to date with regard to DNAR procedures.
7. Competence
All ambulance clinicians must be trained in current DNAR and ROLE procedures as per JRCALC and Coast Medic guidelines.
All staff will follow the current Consent and Capacity policy in relation to DNAR and ADRT orders.
8. Monitoring
This policy will be monitored by the following methods;
All clinicians are required to ensure that they participate in training on DNAR procedures as part of their continued professional development (CPD). The CPD profiles of staff will be monitored by the Operations Manager
Any incidents, complaints or feedback regarding DNAR will be reported via the normal incident reporting mechanisms to the Incident reporting systems in place.
9. Audit and Review
The policy will be reviewed on an bi-annual basis by the Medical Director and amended accordingly if required.
Any such incidents will be monitored in accordance with the Incident Reporting Procedure
10. References
JRCALC UK Ambulance Service Clinical Practice Guidelines 2018
11. Appendix A: Who can be the responsible clinician?
“The overall responsibility of implementing a DNAR rests with the most senior clinician in charge of the patient’s care. It could be a General Practitioner, a Consultant, a Registrar or suitably experienced nurse. They should always be prepared to discuss the DNAR for the patient with other health professionals involved in the patient’s care.”
12. Appendix B: JRCALC Recognition of Life Extinct Guideline 2018 – DNAR extract.
Ambulance clinicians should initiate resuscitation unless:
A formal DNAR order is in place, either written and handed to the ambulance crew or verbally received and recorded by Ambulance Control from the patient’s attendant requesting the ambulance providing that:
The order is seen and corroborated by the ambulance crew on arrival
The decision to resuscitate relates to the condition for which the DNAR order is in force: resuscitation should not be withheld for coincidental conditions.