Contents
1 Aim
Within Rotherham Doncaster and South Humber NHS Foundation Trust (the trust) physically ill children under 16 will be under the care of a consultant from a neighbouring acute trust. However, these children maybe looked after within the community by our trust services.
At the time of writing this procedure there are two documents that may be used to document the resuscitation status of a child under the age of 16 1) DNACPR V13 or 2) ReSPECT document, the use will be specific to the area in which it was raised. Please see the ReSPECT Procedure for emergency care planning and DNACPR decisions that have used this process.
The clinical circumstances that surround cardiorespiratory arrest in children differ from those of adults; the legal and ethical aspects also differ. The use of limitation of treatment agreements are more commonly used within children’s inpatient services as children are less likely than adults to have a sudden cardiorespiratory arrest.
It is vital that when these agreements have been made that the child is offered the same treatment by all clinicians involved in their care. The trust has a responsibility to ensure that any children in our care with life limiting conditions, or at the end of their life should be afforded the same dignity as the looked after adults seen by other clinicians in the trust.
The aim of this procedure is to ensure that trust staff are aware of their responsibilities surrounding do not attempt cardio pulmonary resuscitation (DNACPR) decisions; implementation, communication and review, by having a transparent system to avoid inappropriate resuscitation.
The procedure aims to ensure a consistent approach to DNACPR decisions for children across the Trust and to ensure that decisions that have been made about children in other specialist services can transfer between the different services and localities of the trust and that the trust does not compromise patient care.
The procedure outlines the duties and responsibilities of the trust to comply with relevant legislation and guidance, and to monitor compliance with the manual so that an effective service is provided
1.1 Definitions
| Term | Definition |
|---|---|
| Cardiopulmonary resuscitation | CPR resuscitation is a combination of external chest compressions, artificial respiration, and defibrillation. It is undertaken to restore breathing and circulation in a person where these life giving functions have failed |
| Do not attempt cardiopulmonary resuscitation order | DNACPR is an order stating that a decision has been made either by the patient or the medical officer in charge of their care that CPR would have no clinical benefit or be wished for in this situation. It does not mean that treatment will be withheld, for example, antibiotics, analgesia, feeding, hydration, suction, treatment for choking and so on |
| Medical officer in charge of patient care | In inpatient care this will be the patient’s consultant and in the community, the patient’s GP |
| Healthcare professional | A registered nurse, doctor, or allied healthcare professional |
| Young person | Within the context of this policy, the term young person refers to any patient aged 16 or 17 years of age |
| Child | Within the context of this policy, the term child refers to patients who are under the age of 16 |
| Futility | When treatment is considered unable to produce the desired benefit because it cannot achieve its physiological aim, for example, there is no real prospect of restarting the heart and breathing for a sustained period of time |
2 Scope
This procedure applies to all managers with responsibilities derived from it, and all clinical staff with direct service user contact, including bank, agency, and temporary staff.
3 Link to overarching policy
The procedure should be read as part of the resuscitation manual and the associated documents.
- Resuscitation manual (includes the deteriorating patient, DNACPR adult, DNACPR adult and ReSPECT).
4 Procedure
If a child within the care of the RDaSH children’s services has an existing DNACPR order within another organisation, the lead RDaSH clinician should liaise with the child’s consultant from the other organisation to discuss this. A copy of the DNACPR should be sought and this should be discussed with the trust medical director as soon as possible. If the medical director, patient and family agree that the order still applies the copy of the order should be accepted. The trust medical director will then complete the letter in appendix L and attached this to the DNACPR form.
4.1 Communication of the order
The lead RDaSH clinician must ensure that all clinicians involved in the child’s care are aware of the order.
The order must remain with the child. Discussions should be held with the child if possible, and their parents as to the importance of ensuring the document go with the child when they are attending services, school and so on.
To cancel a DNACPR order, the original form must be marked with two thick diagonal lines and the word cancelled should be written across the form with the date and the signature of the clinician cancelling the form.
4.2 Presumption to resuscitate
“All patients being attended by a clinician, whether in hospital, healthcare unit or their own home, are to be actively and vigorously resuscitated and suitable assistance called, unless they have a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) order in place.” (Rotherham Doncaster and South Humber resuscitation manual).
Where no decision has been made about CPR before any subsequent cardiopulmonary arrest, and the express wishes of the person are unknown it is expected that staff would attempt resuscitation.
“Where no explicit decision about CPR has been considered and recorded in advance there should be an initial presumption in favour of CPR. However, in some circumstances where there is no recorded explicit decision (for example a person in the advanced stages of a terminal illness where death is imminent and unavoidable, and CPR would not be successful) a carefully considered decision not to start inappropriate CPR should be supported.” (Resuscitation Council 2021).
Is it important to note that healthcare or nursing assistants must commence CPR if a do not attempt cardiopulmonary resuscitation order is not in place?
In circumstances where CPR has been initiated without the knowledge of an existing DNACPR and this document then come to light, the continuation of CPR would be inappropriate however the decision to stop must come from a senior healthcare professional (doctor or registered nurse). If there is any doubt, CPR should continue until reviewed by the attending paramedic or doctor.
4.3 Review of DNACPR orders
It is good practice to review DNACPR orders and this review should be done at, medical reviews, any change in condition and at a maximum of 6 monthly. As these orders will be raised within a different organisation, and maybe reviewed following a different policy, it will be of benefit for the lead clinician to speak to the originating consultant about review on at least a 6 monthly basis.
5 Appendices
Please see resuscitation manual webpage for appendices attached to this procedure.
- Appendix L DNACPR child under 16 letter
Document control
- Version: 1.
- Date ratified: 8 June 2022.
- Ratified by: Clinical policies review and approval group.
- Name of originator: Resuscitation officer and nurse consultant in palliative care.
- Name of responsible individual: Executive director of nursing and allied health professionals.
- Date issued: 30 June 2022.
- Review date: June 2025.
- Target audience: All clinical staff working in all service areas including the community. All staff working in areas where patients are present including bank, agency and temporary staff.
- Description of change: Integration as procedure to the resuscitation manual.
Page last reviewed: April 24, 2024
Next review due: April 24, 2025