Mike’s Cheeky Blog: a proposal for a different type of DNACPR document.

mike stone 12/07/23 Dignity Champions forum

The PDF explains my suggestion in more detail, but in essence I think we should describe any form which mentions CPR or DNACPR and is attached to a specific patient as 'a CPR form', and that what we should see on the form is information: not 'recommendations' or 'instructions', but information. And the information we can see, should be 'what I would do if the patient had a cardiopulmonary arrest NOW'.

It is better for me to suggest that readers look at the PDF, than for me to try and explain further here.

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mike stone 23/09/23

Often, patients are told [or given the opportunity to] to record 'wishes and preferences' and those things are, when a patient has lost mental capacity, supposed to be considered by anyone who is making an MCA best-interests determination.

But, CPR and DNACPR come down to a binary choice. If asked 'Do you want a cup of coffee, or do you want a cup of tea' you either choose one, or decline both. If you say 'I usually prefer tea' you could then reasonably be asked 'Does that mean you want a cup of tea, now?'.

Expressing, in the context of future CPR, 'a preference for or against attempted CPR' is questionable on the grounds of 'strength' - how strong does 'a preference for DNACPR' have to be, to justify a 999 paramedic [for example] withholding CPR?

Nobody present when a patient of loved-one has a cardiopulmonary arrest, can act somewhere between attempting CPR and withholding CPR: you can't actually have in terms of an action, the equivalent of 'I like tea and coffee equally'. Either you attempt CPR, or you decide to not attempt CPR if you can perform CPR. Or, you support CPR by perhaps phoning 999, or try to prevent CPR by not calling 999, if you cannot yourself attempt CPR - that being the choice many family-carers will have to make. 'Doing nothing' is in practice the same as not supporting CPR.

But we really should be trying to get patients to express not 'a preference about CPR' but a clear statement: 'I would never want CPR, if my heart has stopped for any reason at all'; 'I would always want CPR - I want every intervention which might keep me alive, even the chances of success are tiny, to be attempted'; or perhaps a 'decision with a qualification'. Recording 'The patient's preference for or against CPR', simply isn't a clear-enough 'instruction/statement'.

And, none of the above, is supposed to imply that if you ask a person 'Would you want CPR?' that they are not 100% entitled to answer 'I don't know'; 'I can't think about that!'; 'I don't want to decide, until I'm more ill than I am at the moment'; etc.

I'll leave clinicians, to explain the difficulty posed by a patient saying 'Oh - I want CPR, but only if after CPR I would be as healthy as I am at the moment, if CPR restarted my heart'. That, as it happens, is I suspect the answer most people would be likely to give!

mike stone 27/09/23

In my PDF, I didn't really elaborate on what '... move the rest into training' implied.

Well, all of the guidance about DNACPR, does state what amounts to 'unless something new or not-previously-considered makes DNACPR inappropriate at the time of the arrest' - i.e. that between creating a DNACPR document and a future arrest, things can change.

Usually, clinically-authored material implies that this 'thing which has changed or wasn't considered' is a clinical factor: but, it doesn't have to be a clinical factor at all. It can be anything, which would have affected the 'CPR or DNACPR?' decision when that decision was being considered. And, if the patient is menatally-capable when the DNACPR is completed and afterwards, the patient subsequently expressing a change of mind about CPR definitely counts.

The crucial piece of logic, if a 999 paramedic or other 'emergency clinician' was reading my form, amounts to 'These people had plenty of time to think about CPR/DNACPR, they were clearly talking to each other and should all have been well-informed, and they weren't doing everything with no time to think [like I am!]: so, if they have been trying to keep this form up-to-date, what could I observe when I arrive to find a patient in arrest, which could make me think I understand the situation better than those people who were involved when the DNACPR was created?'. Viewed in that light, 'what I would do if the patient arrested now' recorded on a form which is being kept up-to-date, is equivalent to 'a recommendation to a future reader'.

I will not deny, that I definitely want these forms to make it clear (and I believe that adding signatures beyond those of clinicians is the best way to achieve this) that End-of-Life, and especially End-of-Life-at-Home, involves many more people than simply the clinicians, and that 'who can legitimately decide what?' is a question which does NOT lead to the answer 'just the GP' or 'just the Consultant Doctor'.

CPR/DNACPR and Mental Capacity Act best-interests decision-making, is definitely not 'the doctor decides' and forms which reflect that fact, will promote an understanding of it.