Teaching session - Ceiling of care in the NHS and discussing DNACPRs.
This post is just an educational post. This is not MEANT as a resource for doctors working in the NHS as they have their own local guidelines and they MUST observe someone who has done it multiple times before ( ie- a consultant or a registrar), do this under supervision ( of a registrar or consultant), then do this independently and then teach. I am making this to share with medical students, international medical graduates and just to give an idea about the importance of ceiling of care in the NHS.
What happens if a patient stops breathing/their heart stops beating?
A CRASH call is put out.
What is a CRASH call?
This a fast bleep to all relevant on call doctors, nurses and other health care professionals which include:
1. The ITU registrar on call
2. The ITU SHO on call
3. The critical care outreach nurse
4. CCU nurse
5. Medical registrar on call
6. Medical on call doctors - SHOs and FY1s
7. Porter
8. Bed manager
9. Matron
10. Resus officer on call
The team may vary from trust to trust but as you can see there are at least 10 people to help.
I have explained the whole process here in detail:
http://omarsguidelines.blogspot.com/2017/12/my-guideline-for-als.html
What does ceiling of care mean?
It is what the maximum therapy which is appropriate for a patient when (s)he becomes unwell
Ie whether the patient is for
1. For full escalation
2. For ward based care but for NIV/CPAP but not for CPR, intubation
3. Ward based case only - not for NIV, CPAP and not for CPR/intubation
4. Palliate if deterioates
Who establishes these ceilings of care?
They may have a :
1. DNACPR/ RESPECT form in the community
2. An advanced directive
3. The doctor looking after the patient decides.
How does the doctor decide?
This comes with experience. Usually an experienced FY2/SHO can make a decision. The registrar and consultant are expected to make decision. Ideally, this decision should be made when the patient is clerked and it MUST be made when the consultant post takes the patient
( Read this blog to understand what clerking, post taking means:
http://omarsguidelines.blogspot.com/2017/05/guideline-for-on-calls.html )
The escalation plan may change if (s)he deteriorates and this is NOT a permanent decision.
Can you give some examples?
FOR WARD BASED CARE ONLY
1. A 90 year old, with dementia, nursing home resident, dependent on carers for all activities of daily living , admitted with community acquired pneumonia
2. A 75 year old, severe heart failure with a poor ejection fraction, multiple regional wall motion abnormalities on ECHO, not for CRT-D as per cardiology letters, admitted with worsening shortness of breath.
3. A 70 year old, severe COPD, still actively smoking, admitted with acidosis, type 2 respiratory failure, unable to tolerate NIV despite giving medications to help him relax.
FOR WARD BASED CARE BUT FOR NIV IF REQUIRED
80 year old, known COPD, exercise tolerance: 50 yards on a good day. Has a stair lift at home, wife is main carer but struggling. Admitted with shortness of breath. ABG: Acidotic with type 2 respiratory failure. CXR shows hyperinflated lungs. Currently on back to back nebs, steroids, antibiotics for an infective exacerbation of his underlying COPD.
What do you do you have established that a patient is for ward based care only?
I discuss escalation of therapy with the patient. If the patient lacks capacity, I talk to the next of kin- ideally face to face. If the patient is very unwell and I need to make a decision AND the next of kin is unable to come to hospital, I call the next of kin and after taking permission to discuss this on the phone, I talk about this on the phone.
Why is this so important?
The chances of surviving CPR/intubation in elderly/frail/patients with end stage disease is very poor.
CPR results in rib fractures which cause pain, trauma to underlying lung causing hemorrhage, pnuemothorax, recurrent infections due to depressed inspiration.
Intubation comes with its own risks - failure to extubate successfully which then means either making a tracheostomy or considering extubating the patient in ITU and let him/her pass away ( which is more traumatic for the family). The patient may have an aspiration pnuemonia, ventilator associated pnuemonia if (s)he is frail. There are also side effects of the sedation needed to intubate a patient.
Hence, if this is not appropriate we should make clear decisions where appropriate about escalation plans after discussion with the patient/next of kin.
Also, stopping a CRASH call when the patient does not have ROSC and (s)he is elderly/frail/has end stage disease is very traumatic for the patient as well as for the CRASH team.
How do you do this?
This does not only involve talking. This involves showing empathy and emotions. This is something the patient/ next of kin will remember for the rest of their lives. This is also a common theme for complaints - as the patient/family do not think that the doctor has explained this process in detail.
So here are a few important steps
THE APPROPRIATE TIME TO DO THIS
You should do this AFTER clerking the patient if it is a new admission or AFTER going through the patients notes, examining the patient if (s)he is a current admission on the ward.
Do this ONCE you have established a good relationship with the patient
However, there are exceptions to the rule - ie, when the patient is imminent and you have been handed over the case in detail by another health care professional.
TIME
You need time to discuss this. It can take 2 to 30 minutes. Or even more.
CAPACITY
Assess the capacity of the patient. You can easily establish this if you have clerked the patient ( the clerking proforma has an AMTS score/ 4 AT score) or have examined the patient in detail on the ward/gone through the patients notes.
SITUATION
You need to discuss this in private. If the patient has capacity, sit next to the patient, request the family members to leave the bedside for a moment.
If the patient lacks capacity, take the next of kin to a private relatives room. Out of hours, the nurse in charge of the patient usually knows whether the patient is more confused than usual and if the patient can make a decision.
BLEEP
If you are the on call doctor, you are carrying the CRASH bleep. If you are in a small DGH and are carrying the registrar bleep, you may be the ONLY registrar and hence cannot hand the bleep to anyone else. I carry my bleep throughout and if there is a CRASH call, I either excuse myself to come back later or try to summarize the consultation and attend the CRASH call.
Either way, ensure you are very clear in your discussion and assure the patient/NOK.
What do you say to a patient?
This depends on the situation and everyone has their own way of talking about this.
This is how I go ahead ( after the aforementioned steps):
"Have you heard about a do not attempt cardiac and breathing resuscitation also known as a do not resuscitate form ( DNACPR)?"
No
"Is it okay if I discuss this with you"
Sure.
"Before I go any further I want to assure you that you are not imminent however I would like to discuss this as you have that mental ability to think about this"
Okay
"When someone's heart stops beating in hospital, we call a team of doctors and nurses. They try to revive the heart by pressing aggressively on the chest, known as chest compression and put a tube down the throat to give oxygen to the lungs. The chances of surviving this when you are young - that is, at the age of 20 and do not have any medical conditions , is 20%. As you grow older and have other medical conditions, the chances of surviving this becomes even less. Going through this prolongs ones agony in the last few minutes or hours of ones life and there is very little chance of surviving it. Does this make sense?"
Yes.
"As a doctor, I am very worried that when your heart stops or you stop breathing and stop breathing, your last few minutes or hours of life will be in agony and distress if you undergo the process of chest compression and the process of putting tubes down your throat. I feel that when the time comes, we let you pass away naturally rather than putting you through any agony."
I pause to let this sink in.
" However I assure you that we will treat you actively, on the ward and continue observing you, do blood tests and any other investigations. I am only talking about the time when your heart stops beating or you stop breathing. Is this clear?"
Yes.
" Is it okay with you if if I put a form in your notes stating that we have had this discussion and both of us agree that this is appropriate"
Yes.
"Again, I wanted to assure you that we are not signing you off and we will continue to investigate, treat and monitor you"
Okay.
"Would you want us to inform your next of kin about this as well?"
Yes.
Thank you. Here is a leaflet on what we have discussed ( we have a patient information leaflet on "what to do when your heart stops beating"). We will inform your next of kin as soon as possible.
What if the patient lacks capacity?
I discuss this with the next of kin - preferably face to face.
What if the next of kin cannot come to discuss this?
I then discuss this on the phone.
I start off with
" Are you aware that Mr/Mrs/Miss X is in hospital?"
Yes
"Do you know what brought him/her in?"
Yes - explains what happened.
I then explain what we our management plan is.
"Is it okay if I discuss something important with you on the phone. I would prefer that we talk about this face to face but I appreciate that you cannot come in at the moment"
Yes
"The reason I am discussing this with you is because Mr/Mrs/Miss X is confused and cannot make a decision and hence I would like to involve you in this"
Okay
"I wanted to discuss... and I continue exactly the same way I did above ( with the patient)"
I mention this on a regular basis in the conversation as well:
"Please do not feel burdened that you have made a decision about this. This is a medical decision however we always like to inform the relatives to ensure that we are on the same page. I hope you understand."
How do you document this?
DOCUMENTATION IS KEY!!! Always document as if these notes will be shown in court. Ie, it should be clear, what the patients/NOKs wishes are and if there were any questions.
Sign the DNACPR form and ensure you tick all the correct boxes. The forms are region specific and hence may be a bit different.
In my trust, I:
1. Attach stickers onto the original form and the carbon copy under it.
2. Fill out the next of kins details.
3. Tick the appropriate section about discussion with the patient
4. Tick the "valid till end of life"
5. Sign and date the form with my details, my role and my GMC number.
What if the patient/next of kin do not agree?
I apologize for not being clear enough and give them a leaflet on "what to do when your heart stops beating" so that they can read about this in detail.
The aforementioned points can be very overwhelming and hence there can be a few reasons why they do not agree:
1. You are not clear enough. You might want to explain it again and also ask them what is important to them. Some say that quality of life is essential.
You can mention things like "Even if there is a small chance of surviving the whole process, it can result in fractured ribs, strokes, leaving a person weak and prone to infections"
2. They want some time to think over it. Ask them that you can come back later and discuss this with them in a few hours.
3. The clearly refuse and have capacity. They understand the risks.
In this situation I get a second opinion- from my consultant/ ITU team.
Till then, the patient remains for full escalation.
How many times has a patient not agreed to a DNACPR form?
I have worked in the NHS for 4 years now and I have not had a single issue.
I am a GP. Will I need to discuss this?
Yes - actually a lot of GPs discuss this as they see frail patients in their clinics and the patients know their GPs well. I personally feel that GPs are actually the best healthcare professionals to discuss this.
Important points about DNACPR forms:
1. This is a medical decision
2. The patients need reassurance that you are not signing them off and that you will still continue to monitor them.
3. You STILL need an escalation plan. Again, this is a medical decision as well.
- Whether the patient is for NIV
- Whether the patient is for inotropic support.
Hence, the summary of such documentation is :
"Escalation plan:
- DNACPR
- However still for NIV if required ( currently NOT indicated)"
OR
"Escalation plan:
DNACPR
NOT for NIV ( Hence NOT for further ABGs)"
4. Documentation is very important as I have mentioned above.
5. Please make a decision about escalation if you are reviewing a sick patient. There are 3 ways a sick patient can be escalated:
- For full escalation
- DNACPR but for NIV if necessary
- DNACPR, ward based care only.
As a SHO, you are expected to have an idea of these 3 pathways and as a registrar, you are EXPECTED to make a decision on this.
I always discussed escalation plans with patients even as a SHO and this helped me develop my communication and empathy skills. I first observed few registrars and consultants discuss this, practiced in a simulation session, then under supervision and then did it independently. Please remember that if done properly, the patient can be assured and if not done well, it can be a complaint which can escalate. So go through proper training and then do it under supervision. Continue doing this.
As a medical registrar, it is very traumatic for me to lead CRASH calls on elderly frail patient who do not have a proper escalation plan and then if it is deemed inappropriate, making a decision to stop CPR after asking the CRASH team if they are in agreement. Hence, it is my request to everyone who clerks such patients to make decisions early and ask your consultants to make these decisions if you are unable to do so.
Try to improve your communication skills as it is essential not only in medical and surgical specialties but also GP practice.
I hope this blog post helps.
I will be arranging some face to face sessions in my trust- Scarborough Hospital and also deanery based sessions to help improve communication skills of health care professionals.
If you have any questions and need help, I am happy to help. Please message me here:
https://www.facebook.com/omar.ay.37
What happens if a patient stops breathing/their heart stops beating?
A CRASH call is put out.
What is a CRASH call?
This a fast bleep to all relevant on call doctors, nurses and other health care professionals which include:
1. The ITU registrar on call
2. The ITU SHO on call
3. The critical care outreach nurse
4. CCU nurse
5. Medical registrar on call
6. Medical on call doctors - SHOs and FY1s
7. Porter
8. Bed manager
9. Matron
10. Resus officer on call
The team may vary from trust to trust but as you can see there are at least 10 people to help.
I have explained the whole process here in detail:
http://omarsguidelines.blogspot.com/2017/12/my-guideline-for-als.html
What does ceiling of care mean?
It is what the maximum therapy which is appropriate for a patient when (s)he becomes unwell
Ie whether the patient is for
1. For full escalation
2. For ward based care but for NIV/CPAP but not for CPR, intubation
3. Ward based case only - not for NIV, CPAP and not for CPR/intubation
4. Palliate if deterioates
Who establishes these ceilings of care?
They may have a :
1. DNACPR/ RESPECT form in the community
2. An advanced directive
3. The doctor looking after the patient decides.
How does the doctor decide?
This comes with experience. Usually an experienced FY2/SHO can make a decision. The registrar and consultant are expected to make decision. Ideally, this decision should be made when the patient is clerked and it MUST be made when the consultant post takes the patient
( Read this blog to understand what clerking, post taking means:
http://omarsguidelines.blogspot.com/2017/05/guideline-for-on-calls.html )
The escalation plan may change if (s)he deteriorates and this is NOT a permanent decision.
Can you give some examples?
FOR WARD BASED CARE ONLY
1. A 90 year old, with dementia, nursing home resident, dependent on carers for all activities of daily living , admitted with community acquired pneumonia
2. A 75 year old, severe heart failure with a poor ejection fraction, multiple regional wall motion abnormalities on ECHO, not for CRT-D as per cardiology letters, admitted with worsening shortness of breath.
3. A 70 year old, severe COPD, still actively smoking, admitted with acidosis, type 2 respiratory failure, unable to tolerate NIV despite giving medications to help him relax.
FOR WARD BASED CARE BUT FOR NIV IF REQUIRED
80 year old, known COPD, exercise tolerance: 50 yards on a good day. Has a stair lift at home, wife is main carer but struggling. Admitted with shortness of breath. ABG: Acidotic with type 2 respiratory failure. CXR shows hyperinflated lungs. Currently on back to back nebs, steroids, antibiotics for an infective exacerbation of his underlying COPD.
What do you do you have established that a patient is for ward based care only?
I discuss escalation of therapy with the patient. If the patient lacks capacity, I talk to the next of kin- ideally face to face. If the patient is very unwell and I need to make a decision AND the next of kin is unable to come to hospital, I call the next of kin and after taking permission to discuss this on the phone, I talk about this on the phone.
Why is this so important?
The chances of surviving CPR/intubation in elderly/frail/patients with end stage disease is very poor.
CPR results in rib fractures which cause pain, trauma to underlying lung causing hemorrhage, pnuemothorax, recurrent infections due to depressed inspiration.
Intubation comes with its own risks - failure to extubate successfully which then means either making a tracheostomy or considering extubating the patient in ITU and let him/her pass away ( which is more traumatic for the family). The patient may have an aspiration pnuemonia, ventilator associated pnuemonia if (s)he is frail. There are also side effects of the sedation needed to intubate a patient.
Hence, if this is not appropriate we should make clear decisions where appropriate about escalation plans after discussion with the patient/next of kin.
Also, stopping a CRASH call when the patient does not have ROSC and (s)he is elderly/frail/has end stage disease is very traumatic for the patient as well as for the CRASH team.
How do you do this?
This does not only involve talking. This involves showing empathy and emotions. This is something the patient/ next of kin will remember for the rest of their lives. This is also a common theme for complaints - as the patient/family do not think that the doctor has explained this process in detail.
So here are a few important steps
THE APPROPRIATE TIME TO DO THIS
You should do this AFTER clerking the patient if it is a new admission or AFTER going through the patients notes, examining the patient if (s)he is a current admission on the ward.
Do this ONCE you have established a good relationship with the patient
However, there are exceptions to the rule - ie, when the patient is imminent and you have been handed over the case in detail by another health care professional.
TIME
You need time to discuss this. It can take 2 to 30 minutes. Or even more.
CAPACITY
Assess the capacity of the patient. You can easily establish this if you have clerked the patient ( the clerking proforma has an AMTS score/ 4 AT score) or have examined the patient in detail on the ward/gone through the patients notes.
SITUATION
You need to discuss this in private. If the patient has capacity, sit next to the patient, request the family members to leave the bedside for a moment.
If the patient lacks capacity, take the next of kin to a private relatives room. Out of hours, the nurse in charge of the patient usually knows whether the patient is more confused than usual and if the patient can make a decision.
BLEEP
If you are the on call doctor, you are carrying the CRASH bleep. If you are in a small DGH and are carrying the registrar bleep, you may be the ONLY registrar and hence cannot hand the bleep to anyone else. I carry my bleep throughout and if there is a CRASH call, I either excuse myself to come back later or try to summarize the consultation and attend the CRASH call.
Either way, ensure you are very clear in your discussion and assure the patient/NOK.
What do you say to a patient?
This depends on the situation and everyone has their own way of talking about this.
This is how I go ahead ( after the aforementioned steps):
"Have you heard about a do not attempt cardiac and breathing resuscitation also known as a do not resuscitate form ( DNACPR)?"
No
"Is it okay if I discuss this with you"
Sure.
"Before I go any further I want to assure you that you are not imminent however I would like to discuss this as you have that mental ability to think about this"
Okay
"When someone's heart stops beating in hospital, we call a team of doctors and nurses. They try to revive the heart by pressing aggressively on the chest, known as chest compression and put a tube down the throat to give oxygen to the lungs. The chances of surviving this when you are young - that is, at the age of 20 and do not have any medical conditions , is 20%. As you grow older and have other medical conditions, the chances of surviving this becomes even less. Going through this prolongs ones agony in the last few minutes or hours of ones life and there is very little chance of surviving it. Does this make sense?"
Yes.
"As a doctor, I am very worried that when your heart stops or you stop breathing and stop breathing, your last few minutes or hours of life will be in agony and distress if you undergo the process of chest compression and the process of putting tubes down your throat. I feel that when the time comes, we let you pass away naturally rather than putting you through any agony."
I pause to let this sink in.
" However I assure you that we will treat you actively, on the ward and continue observing you, do blood tests and any other investigations. I am only talking about the time when your heart stops beating or you stop breathing. Is this clear?"
Yes.
" Is it okay with you if if I put a form in your notes stating that we have had this discussion and both of us agree that this is appropriate"
Yes.
"Again, I wanted to assure you that we are not signing you off and we will continue to investigate, treat and monitor you"
Okay.
"Would you want us to inform your next of kin about this as well?"
Yes.
Thank you. Here is a leaflet on what we have discussed ( we have a patient information leaflet on "what to do when your heart stops beating"). We will inform your next of kin as soon as possible.
What if the patient lacks capacity?
I discuss this with the next of kin - preferably face to face.
What if the next of kin cannot come to discuss this?
I then discuss this on the phone.
I start off with
" Are you aware that Mr/Mrs/Miss X is in hospital?"
Yes
"Do you know what brought him/her in?"
Yes - explains what happened.
I then explain what we our management plan is.
"Is it okay if I discuss something important with you on the phone. I would prefer that we talk about this face to face but I appreciate that you cannot come in at the moment"
Yes
"The reason I am discussing this with you is because Mr/Mrs/Miss X is confused and cannot make a decision and hence I would like to involve you in this"
Okay
"I wanted to discuss... and I continue exactly the same way I did above ( with the patient)"
I mention this on a regular basis in the conversation as well:
"Please do not feel burdened that you have made a decision about this. This is a medical decision however we always like to inform the relatives to ensure that we are on the same page. I hope you understand."
How do you document this?
DOCUMENTATION IS KEY!!! Always document as if these notes will be shown in court. Ie, it should be clear, what the patients/NOKs wishes are and if there were any questions.
Sign the DNACPR form and ensure you tick all the correct boxes. The forms are region specific and hence may be a bit different.
In my trust, I:
1. Attach stickers onto the original form and the carbon copy under it.
2. Fill out the next of kins details.
3. Tick the appropriate section about discussion with the patient
4. Tick the "valid till end of life"
5. Sign and date the form with my details, my role and my GMC number.
What if the patient/next of kin do not agree?
I apologize for not being clear enough and give them a leaflet on "what to do when your heart stops beating" so that they can read about this in detail.
The aforementioned points can be very overwhelming and hence there can be a few reasons why they do not agree:
1. You are not clear enough. You might want to explain it again and also ask them what is important to them. Some say that quality of life is essential.
You can mention things like "Even if there is a small chance of surviving the whole process, it can result in fractured ribs, strokes, leaving a person weak and prone to infections"
2. They want some time to think over it. Ask them that you can come back later and discuss this with them in a few hours.
3. The clearly refuse and have capacity. They understand the risks.
In this situation I get a second opinion- from my consultant/ ITU team.
Till then, the patient remains for full escalation.
How many times has a patient not agreed to a DNACPR form?
I have worked in the NHS for 4 years now and I have not had a single issue.
I am a GP. Will I need to discuss this?
Yes - actually a lot of GPs discuss this as they see frail patients in their clinics and the patients know their GPs well. I personally feel that GPs are actually the best healthcare professionals to discuss this.
Important points about DNACPR forms:
1. This is a medical decision
2. The patients need reassurance that you are not signing them off and that you will still continue to monitor them.
3. You STILL need an escalation plan. Again, this is a medical decision as well.
- Whether the patient is for NIV
- Whether the patient is for inotropic support.
Hence, the summary of such documentation is :
"Escalation plan:
- DNACPR
- However still for NIV if required ( currently NOT indicated)"
OR
"Escalation plan:
DNACPR
NOT for NIV ( Hence NOT for further ABGs)"
4. Documentation is very important as I have mentioned above.
5. Please make a decision about escalation if you are reviewing a sick patient. There are 3 ways a sick patient can be escalated:
- For full escalation
- DNACPR but for NIV if necessary
- DNACPR, ward based care only.
As a SHO, you are expected to have an idea of these 3 pathways and as a registrar, you are EXPECTED to make a decision on this.
I always discussed escalation plans with patients even as a SHO and this helped me develop my communication and empathy skills. I first observed few registrars and consultants discuss this, practiced in a simulation session, then under supervision and then did it independently. Please remember that if done properly, the patient can be assured and if not done well, it can be a complaint which can escalate. So go through proper training and then do it under supervision. Continue doing this.
As a medical registrar, it is very traumatic for me to lead CRASH calls on elderly frail patient who do not have a proper escalation plan and then if it is deemed inappropriate, making a decision to stop CPR after asking the CRASH team if they are in agreement. Hence, it is my request to everyone who clerks such patients to make decisions early and ask your consultants to make these decisions if you are unable to do so.
Try to improve your communication skills as it is essential not only in medical and surgical specialties but also GP practice.
I hope this blog post helps.
I will be arranging some face to face sessions in my trust- Scarborough Hospital and also deanery based sessions to help improve communication skills of health care professionals.
If you have any questions and need help, I am happy to help. Please message me here:
https://www.facebook.com/omar.ay.37
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