Resuscitation manual

1 Introduction

The decision and procedure to resuscitate, or not when there is a valid do not attempt cardio-pulmonary resuscitation (DNACPR) decision in place for both adults and children within the trust are all in one manual. The introduction of, and rationale for, each procedure will be within the relevant chapter.

2 Purpose

The purpose of this manual and the linked procedure documents is to provide clear, concise guidance on managing, for both adults and children:

• the risks associated with resuscitation
• the systems in place to support effective resuscitation provision
• the deteriorating patient
• do not attempt cardio-pulmonary resuscitation (DNACPR) decision
• recommended summary plan for emergency care and treatment (ReSPECT)

The manual outlines the duties and responsibilities of the trust to comply with the relevant local and national legislation and guidance and monitor compliance with this manual so that an effective service is provided.

3 Scope

This manual applies to all managers with responsibilities derived from it, and all staff (clinical and non-clinical), including bank, agency and temporary staff who may need to summon help if they come in to contact with a patient, visitor or member of staff who becomes acutely unwell.

4 Responsibilities, accountabilities and duties

4.1 Chief executive

The chief executive is responsible for making arrangements to support the safe and effective implementation, monitoring and review of this policy manual.

4.2 Medical director and chief operating officer

These directors are responsible for implementation and monitoring of the policy manual within their areas of responsibility.

4.3 Consultants and medical officers

Consultants and medical officers in charge of patients’ care retain overall responsibility for the decisions relating to procedures within this policy manual.

4.4 Resuscitation Committee

The Resuscitation Committee are responsible for reviewing the trust’s assurance processes within this policy manual and to oversee the annual audit work plan adhering to the UK Resuscitation Council Quality Standards (see appendix A).

4.5 Resuscitation service

• Liaise with managers or modern matrons to formulate suitable staff training programmes to support effective implementation of this policy manual.
• Deliver training using the current national guidelines.
• Maintain a central record of training delivered and produce reports on training compliance.
• Discuss with the managers or modern matrons the approach to be taken with staff who do not successfully complete the training assessments.
• Act as specialist advisors to the trust on resuscitation and related matters.
• Produce an annual audit of resuscitation events, resuscitation equipment, choking incidents and do not attempt cardio-pulmonary resuscitation (DNACPR) or recommended summary plan for emergency care and treatment (ReSPECT) orders.
• Produce a quarterly audit report on the continual availability of equipment, see appendix D, emergency equipment required in healthcare areas.
• Facilitate policy and practice development and organisational learning as a result of audit.
• Support Managers in facilitating an environment where incidents are reviewed in an open and positive manner, involving staff at all levels in improving practice and promoting organisational learning
• Be available as a source of specialist advice and support to managers and staff, including incident debriefing.
• Represent the trust on the regional DNACPR working party and the Doncaster locality End of Life group as the DNACPR lead for the trust.
• Lead the review and updating of this policy.

4.6 Managers or modern matrons

• Disseminate, implement and monitor implementation of this policy manual within areas of responsibility.
• Facilitate, support and monitor ward or team managers in their responsibilities with regard to policy implementation and monitoring.
• Identify and allocate resources in order to comply with this policy manual.
• Make available appropriate and suitably maintained resuscitation equipment, maintaining up-to-date medical devices inventories in all areas of responsibility.
• Promote incident reporting and audit requirements as specified within the policy through local induction processes in all areas of responsibility.
• Facilitate an environment where incidents are reviewed in an open and positive manner, involving staff at all levels in improving practice and promoting organisational learning.
• Proactively seek advice and support from the resuscitation service.

4.7 Ward or team managers

• Facilitate effective local induction processes for all new starters
• Manage the process of releasing staff for training and updating at least annually in the skills relevant for their area, in line with the mandatory risk management training policy.
• Maintain staff training records for the area, including temporary, bank and agency staff.
• Proactively identify risks due to lack of training or resources to the manager or modern matron.
• Manage and maintain the resuscitation equipment within the area of responsibility via:
  • an up-to-date medical devices Inventory
  • signed and dated daily and weekly equipment check records (as per requirements set out in appendix D continual availability of equipment, see appendix D, emergency equipment required in healthcare areas), in line with the manufacturer’s recommendations; a record of these checks will be kept for 3 years
  • report any equipment issues immediately to the manager or modern matron
  • adequate stocks of disposable or single use parts of the resuscitation equipment required in that area, such as pocket masks, oxygen masks, airway tubes, defibrillator pads etc. to maintain continued functioning of the equipment by immediate replacement
• Maintain the equipment ready and available for use for another event as soon as practicable after a resuscitation attempt where the equipment is used.
• Make timely arrangements for staff involved in a resuscitation event to be supported, debriefed, and offered counselling as required in conjunction with the resuscitation officer.
• Facilitate an environment where incidents are reviewed in an open and positive manner, involving staff at all levels in developing policy and practice and promoting organisational learning.
• Proactively seek advice and support from resuscitation service.

4.8 Clinical and non-clinical staff

• Adhere and implement this policy manual within the scope of their job role (the resuscitation council expects all staff to recognise cardiac arrest, to commence cardiopulmonary resuscitation and call for help).
• Report any issues which affect the effective implementation of this manual to their manager, for example, access to training or equipment.
• Report all incidents as per the incident reporting policy including the use of the appropriate cardiac arrest report form.
• Maintain a personal record of their own training.
• Contribute to the review of incidents in an open and positive manner in order to improve practice and promote organisational learning.

5 Procedures

5.1 Resuscitation and the deteriorating adult procedure

5.1.1 Aim

The availability of suitable cardio-pulmonary resuscitation is expected of healthcare services, and a service user has the right to expect such support from a healthcare provider. Therefore, it is recognised that employees of Rotherham Doncaster and South Humber NHS Foundation Trust (hereafter known as the trust) may be involved in resuscitation procedures in the course of their work.

As a provider of specialist mental health, learning disability and community services it is essential that the trust provides resuscitation at an appropriate level. For effective life support, standardised equipment, training, and protocols must be provided. Across the trust this provision will be determined by the location of the healthcare facility, the staff available and the type of healthcare provided and will at all times be supported by the local ambulance service.

This procedure outlines the systems in place in the trust to provide high quality resuscitation to its patients at all times.

5.1.1.1 Definitions

5.1.2 Procedure

5.1.2.1 Cardiopulmonary arrest prevention and the deteriorating patient

The resuscitation service will work alongside the trust clinical quality lead (physical health and wellbeing) to promote the importance of physical wellness and healthy lifestyles.

The trust will wherever possible promote the prevention of cardiopulmonary arrest occurring by monitoring and observing:

• physically unwell and deteriorating patients
• those being restrained both during and after the restraint
• those that have been given rapid tranquillisation
• those with Head injuries or possibility of head injury (unwitnessed fall)
• those who have been suspected of using a ligature

Physical observations for these patients will be taken in conjunction with the use of a track and trigger system the National early warning score 2 (NEWS2), a plan for vital signs monitoring that identifies which variables need to be monitored including the frequency of measurements, as advised by the Resuscitation Council, National Institute for Health and Care Excellence (NICE) and National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

To work alongside the NEWS2 and neuro observations the resuscitation service has developed flow charts for both head injuries and ligatures.

5.1.2.2 Emergency lifesaving drugs

The provision of standardised medication to treat the deteriorating patient is vital, therefore, all inpatient areas carry drugs that can be given in emergency situations by a registered nurse, these drugs will be kept in stock medication cupboards, easily accessible at all times, stored with the appropriate paraphernalia to administer, and the appropriate flow chart displayed on the within the cupboard.

These drugs are:

• aspirin
• glyceryl trinitrate (GTN) spray
• naloxone
• glucagon or glucogel
• adrenaline
• oxygen

When an emergency lifesaving drug is administered the following details must be recorded in the patient records: date, time, drug name, strength, dose, route, batch number and expiry date along with the details of the patient’s presentation at the time of administration.

See appendix C for flow charts for administration.

5.1.2.3 Equipment

The provision of suitable, standardised equipment is paramount in resuscitation so that staff are familiar, proficient and confident with the use of that equipment.

For areas revaluating the provision of resuscitation equipment within their areas the trust emergency equipment risk assessment must be used in conjunction with discussions with the resuscitation officer.

Details are shown in appendix D, equipment required in healthcare areas.

5.1.2.4 Initiation of and criteria for resuscitation

All patients, visitors, and staff who collapse within the vicinity of trust premises are to be resuscitated in line with this procedure. 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 cardio-pulmonary resuscitation (DNACPR) order in place, rigour mortis is present, or there are signs of decomposition. The temperature and pallor of the person’s skin should not be used as an indicator of the initiation of cardiopulmonary resuscitation (CPR).

In circumstances where staff think the casualty should have a DNACPR order, but doesn’t, full resuscitation is to be attempted until an ambulance arrives and takes over, or a recognised doctor issues orders to stop resuscitation efforts.

On finding someone collapsed, staff should immediately assess the casualty, using the danger, response, airway, breathing and circulation (DRABC) approach, and summon further assistance by initially shouting for help and activating any alarm systems in place. As soon as a medical emergency has been identified, then an ambulance will be summoned by all areas within Tickhill Road Hospital and Tickhill Road Site.

Dialling: 2222 on the internal phone system, state cardiac arrest, the caller will be given instructions by switchboard staff to enable the call to be transferred to the ambulance service.

• Great Oaks dialling: 9-999
• Woodlands dialling: 9-999
• Swallownest Court dialling: 9-999
• All other areas dialling: 999
• Softphone: 999 goes straight through to emergency services

5.1.2.5 Relatives who choose to witness resuscitation attempts

The Resuscitation Council UK (RCUK) suggested that family members who witness the resuscitation process may have a healthier bereavement, as they will find it easier to come to terms with the reality of their relative’s death and may feel reassured that everything possible has been done. It is acknowledged that the reality of cardiopulmonary resuscitation may be distressing, but in the latest edition of RCUK’s advanced life support manual, the RCUK argues that:

“Many relatives want the opportunity to be present during the attempted resuscitation of their loved one.” (RCUK, 2021).

Each cardiac arrest situation needs to be taken on a case-by-case basis and if there is opportunity and time to invite family members and loved ones to witness the resuscitation process then this should be accommodated. However, as we know there are some situations this may be difficult, and therefore the appropriate support should be offered such as effective communication from one professional from the care team to speak with the family, provision of a suitable room to speak to family, breaking bad news and supporting the grief response, arranging viewing of the body and religious requirements, legal and practical arrangements as stated from the RCUK paper wherever possible.

In the community setting, where staff often visit patients alone, the trust support staff prioritising the clinical emergency first and if there is an opportunity after the event then to support the family.

5.1.2.6 Do not attempt cardio-pulmonary resuscitation orders

In line with the HSC 2000/028, the trust has adopted the Yorkshire and Humber region system whereby a patient or medical officer can withdraw the provision of resuscitation. The trust do not attempt cardio-pulmonary resuscitation (DNACPR) procedure can be found in the do not attempt cardiopulmonary resuscitation within the resuscitation manual. It is the responsibility of all staff to know which process is to be followed for DNACPR in their care group for example, the recommended summary plan for emergency care and treatment (ReSPECT) orders process or version 13 DNACPR.

5.1.2.7 Incident reporting, including external reporting requirements

All resuscitation attempts should be reported on the trust safeguard incident reporting system (IR1) and by the completion of the cardiac arrest report form (appendix E) which must be received by the resuscitation officer within 24 hours of the incident.

All serious (life threatening) sudden medical emergencies, for example, choking and anaphylaxis, and any emergency medical equipment failures should be reported using the trust safeguard incident reporting system (IR1). Patient safety incidents are required to be reported to the National Patient Safety Agency (NPSA), deaths to the coroner’s office and certain deaths to the care quality commission. Please see the incident management policy for details.

5.2 Do not attempt cardiopulmonary resuscitation (DNACPR) adult

5.2.1 Aim

The primary goal of medical treatment is to benefit patients, by restoring or maintaining their health as far as possible, thereby maximising benefit and minimising harm. If treatment fails or ceases to give a net benefit to the patient, or if a patient has competently refused the treatment, this goal cannot be realised and the justification for providing the treatment is removed.

Prolonging a patient’s life usually provides a health benefit to that patient. Nevertheless, it is not an appropriate goal of medicine to prolong life at all costs with no regard to its quality or the burdens of treatment on the patient. There are occasions when due to the nature of someone’s physical state, and quality of life, a decision may be made that in the event of that person experiencing a cardio-respiratory arrest, cardiopulmonary resuscitation would not be desirable. This includes circumstances where a patient is already dying and has a terminal illness. In these circumstances patients should be allowed to die peacefully and with dignity.

Under the provisions of the Mental Capacity Act (2005), patients with capacity can decide that the stage has been reached beyond which, for them, continued treatment aimed at prolonging life, although possible, would be inappropriate. Patients may have also utilised the provisions of the act to identify a point in the future after which they do not want treatment, including life sustaining, and refuse further interventions through an advanced decision. Please refer to the trust’s policy for advance statements and advance decisions

Under the provisions of the Mental Capacity Act (2005) where patients have no advance decision and lack capacity, all decisions about whether to provide treatment must be taken in a way that reflects their best interests. Under the act, patients have the right to appoint an attorney to make healthcare decisions on their behalf.

An attorney can only make life-sustaining treatment decisions if this is made explicit within the lasting power of attorney order. In these circumstances the attorney must always act in the donor’s best interests (Mental Capacity Act (2005) Code of Practice (2007). Please refer to the trust’s Mental Capacity Act (2005) policy.

Where the patient who lacks capacity has no relative or friend to support life-sustaining decisions, the Mental Capacity Act (2005) has made provisions for the instruction of an independent mental capacity advocate to be consulted to support the best interest decision-making process. Please refer to the trust’s Mental Capacity Act (2005) policy.

Any assessment of best interests must include the patient’s clinical presentation and any current and previously expressed wishes and preferences. Where there is no information about their wishes or preferences, decisions must be consistent with and not contrary to their interests or rights. The emphasis on the individual’s interests means that it is important that resuscitation is discussed sensitively with patients who have capacity, and people close to patients who lack capacity including any nominated attorney. This can help people to understand why treatment is given and why, in some circumstances, it may be unable to provide any benefit.

Each case involves an individual patient with their circumstance, and it is important that these circumstances are central to each decision rather than applying the same decision to whole categories of patients. Unless a patient who lacks capacity has an appointed Attorney with explicit powers to make decisions regarding life-sustaining treatment, any decision not to attempt resuscitation is ultimately the responsibility of the medical officer in charge of the patient’s care (see definition section). Good practice however dictates that consultation should, whenever possible, take place with the other members of the team involved in the care of the patient. Provisions are made under the Mental Capacity Act (2005) and its Code of Practice (2007) for referring decisions to the Court of Protection should professionals’ judge that an Attorney is not acting in a donor’s best interest. Please refer to the trust’s Mental Capacity Act (2005) policy.

This procedure is based on the guidelines produced in 2016 by the British Medical Association (BMA), Royal College of Nursing (RCN) and Resuscitation Council (UK) and should be read in conjunction with this document. It is written with due regard for the requirements of the Mental Capacity Act (2005).

This procedure should be read in conjunction with the relevant professional standards and guidelines including the Nursing and Midwifery Council (NMC) publication Professional standards of practice and behaviour for nurses and midwives 2015 and the General Medical Council (GMC) publication, treatment and care towards the end of life; good practice in decision-making (July 2010).

This procedure should be read in conjunction with the recommended summary plan for emergency care and treatment (ReSPECT) for care groups that have adopted this document in place of the version 13 do not attempt cardiopulmonary resuscitation (DNACPR) document.

5.2.1.1 Definitions

5.2.2 Procedure

5.2.2.1 Do not attempt cardiopulmonary resuscitation in inpatient areas

On admission to an inpatient area it is only necessary to discuss the cardiopulmonary resuscitation status of a patient and consider making a do not attempt cardiopulmonary resuscitation decision in the following circumstances:

• where the patient’s condition indicates that cardiopulmonary resuscitation is unlikely to be successful
• where successful cardiopulmonary resuscitation is likely to be followed by a length and quality of life which would not be in the best interests of the patient to sustain
• where cardiopulmonary resuscitation is not in accord with the recorded sustained wishes of a patient who has capacity
• where cardiopulmonary resuscitation is not in accord with a valid applicable written advance decision which demonstrates a patient’s informed, voluntary and competently made refusal, which relates to the circumstances which have arisen, is legally binding upon medical staff

In cases where a patient is admitted to a ward with an existing do not attempt cardiopulmonary resuscitation (DNACPR) order, this order will remain but must be reviewed on the day of admission and an entry made in the patients notes on the DNACPR template (see appendix K). This entry and subsequent entry is to confirm:

• the existence of the order
• the validity of the decision
• the validity of the form itself
• a review of the patient’s capacity in relation to the decision
• patient and relevant others’ knowledge of the decision

Any amendments, omissions, or corrections to existing transferred DNACPR orders must be made by a consultant at the time of admission.

5.2.2.2 Responsibility for making do not attempt cardiopulmonary resuscitation decisions

In trust consultant led inpatient settings the responsibility for making do not attempt cardiopulmonary resuscitation (DNACPR) decisions lies with the patients named consultant after consultation with the multi-disciplinary team, patient and relevant others wherever possible.

In St John’s Hospice any patients requiring a DNACPR decision on admission may be made by the admitting clinician in conjunction with the nursing team, patient and relevant others wherever possible but must be countersigned by the patients’ consultant as soon as is practicable.

5.2.2.3 Nurse led units

On admission to a nurse led unit the admitting nurse must review any existing do not attempt cardiopulmonary resuscitation (DNACPR) forms on admission following the points outlined in the previous paragraph (in cases where a patient is admitted with an existing DNACPR) any issues, omissions or concerns with existing DNACPR orders must be discussed with the clinician responsible for the patient’s care immediately prior to admission and a document of the conversations made in then patients notes (on the DNACPR template). When the responsible clinician is available, they will review DNACPR’s of any new admissions within the overall medical review and make an entry in the patient’s notes.

Any DNACPR decisions required during the inpatient stay will be made by the consultant geriatrician following the procedure set out in this policy manual and procedures.

5.2.2.4 Completion of the do not attempt cardiopulmonary resuscitation version 13 form

All entries into the patient’s medical records related to the do not attempt cardiopulmonary resuscitation (DNACPR) decision should be written on the trust DNACPR template (see appendix K). In a situation where the patient’s condition meets the above-mentioned circumstances all sections of the form must be completed in full.

If cardiopulmonary resuscitation has been discussed with the patient, it is against their wishes, and they have the mental capacity to make this decision, then option A should be ticked and a record reflecting the rationale for the decision and capacity assessment should be recorded on the DNACPR template in the patient’s electronic records.

If cardiopulmonary resuscitation is against the wishes of the patients as recorded in a valid advance decision, then option B should be ticked. Although the advance decision is a legally binding document it is good practice to complete a DNACPR form for ease of communication this must be documented in the patients notes. A copy of the advance decision should be kept with the DNACPR.

If the outcome of cardiopulmonary resuscitation would not be of overall benefit to the patient, and the patient lacks capacity to make the decision (option A would be appropriate if they had capacity) or they have declined to discuss the decision option C should be ticked. This represents a best interest decision and therefore must be discussed with the patient’s relevant others or independent mental capacity advocate. The medical officer must document who the decision was discussed with and record the date and time of this discussion on the form. The patient’s notes must reflect the full rationale for the decision and choice of option C, the capacity assessment and the thoughts and feelings of the relevant others or independent mental capacity advocate.

If cardiopulmonary resuscitation would be of no clinical benefit option D should be ticked and the medical officer must document the medical condition that indicates this decision on the form.

In cases where cardiopulmonary resuscitation would be futile due to the patient’s condition the decision must be discussed with the patient, unless the patient lacks capacity or has refused to discuss this aspect of their care when discussion has been attempted. It is not acceptable for a discussion not to take place just because this may upset the patient. When making a decision that a discussion is not to take place with the patient the medical officer must have a clear rationale that any such discussion would have clear physiological or psychological harm for the patient. If it is not possible to speak to the patient for reasons given above it is important that relevant others are informed of the decision at the nearest possible opportunity. This must not delay the decision, but every effort should be made for discussion with the relevant others. The patients notes must reflect, the medical condition that indicates this decision, any discussions with patients and relevant others including dates and times, capacity assessment of the patient in regard to the DNACPR decision and a rationale for any delay in discussion with the patient or relevant others with a plan for contact if applicable.

Any meeting convened to discuss the decision must be documented clearly in the patient’s notes. The medical officer in charge of the patient’s care will take the lead at any meetings and all relevant information about the patient’s physical condition and mental state must be available so that an informed decision can be made if not already done so.

An information leaflet about do not attempt cardiopulmonary resuscitation (DNACPR) must be available to patients and relevant others. This leaflet (found in appendix O) should be used in circumstances where meetings have been convened to discuss DNACPR as an introduction to the process, where patients have requested discussions about cardiopulmonary resuscitation and when a DNACPR decision has been made and the patient and relevant others wish to have information to take away. DNACPR is an emotional subject, and it is often difficult for patients and their relevant others to know what questions to ask. It is often after the discussions that questions arise. The leaflets do not replace face to face discussion and staff must always be available for these discussions if needed.

The ultimate responsibility for such a decision lies with the medical officer in charge of the patient’s care. Under no circumstances should a relative, friend or other be asked to, or made to feel that they have to, make the decision. Relevant others should, wherever possible, be involved in the discussions that surround the decision-making process, but, the actual decision is for the medical officer in charge of the patient’s care unless a patient with capacity has made the decision either at the time or has made a previous advance directive.

In cases where there has been difficulties making the decision, due to relative, family or multi-disciplinary team disagreements it is advisable to obtain a second opinion. In very rare circumstances where there is ongoing disagreement it is advisable to obtain legal advice. For more information see the Resuscitation Council UK, decisions relating to cardiopulmonary resuscitation.

Whilst the decision will be based on clinical findings the clinical team will also consider the patient’s wishes, including any valid written advance decision. If applicable the best interest decision made by a legally empowered attorney, or a best interest view expressed by an independent mental capacity advocate, must be taken into account. Age, gender, religion, and culture alone will not be factors in the decision.

Note, under no circumstances will any member of the nursing staff who do not have the authority to make DNACPR decisions meet with the relatives, attorney, or independent mental capacity advocate alone to make a DNACPR decision. It must always be conducted by the medical officer in charge of the patient’s care. It may be the case that the initial discussions come from the patients to nursing staff, or it is the nurse that has the better relationship with the patient, in these cases it must be made clear that the decision will be made by the medical officer in charge of the patients care following further discussion with them.

For young people aged 16 and 17, also refer to appendix F for further considerations.

5.2.2.5 Patients with a do not attempt cardiopulmonary resuscitation order on community caseloads

The responsibility for the do not attempt cardiopulmonary resuscitation (DNACPR) order in the community lies with the patients GP.

If a patient is discharged from an inpatient facility with a DNACPR order all professionals involved in the patients care should be advised of its existence on discharge.

If a member of staff has cause to question the validity of a DNACPR order in the community this must be brought to the attention of the patients’ own GP.

5.2.2.6 Communication of the order

• The order is a two-page carbonated form, original and copy, (the copy sheet is watermarked appropriately).
• Whilst in inpatient care, the original order should be kept in the front of the nursing notes, the copy (this will only be available if the order was completed whilst a trust patient) will be kept in the front of the medical notes if available. As patients move between care settings, the original DNACPR version 13 form must move with the patient in a clearly marked envelope.
• In all other care settings, the DNACPR form should be in the front of the care record or nursing record.
• If no nursing record exists in the home, the patient, family and carer will determine the best place to store it. It is then their responsibility to communicate this to the health care professionals.
• In the community DNACPR information should be recorded on the patient’s electronic record as part of their electronic palliative care coordination systems (EPaCCs) information and locally on their alert screen, this information should include where the patient keeps the
  DNACPR document. However, it is imperative that this information is used only as an alert to the existence of a DNACPR order. All staff working with the patient must ensure that they have sight of the original form. The electronic palliative care coordination system has a link to the DNACPR template, all parts must be completed.
• Ambulance control should be informed that a DNACPR form exists at the time of booking patient transport services (PTS) ambulance.
• The discharging organisation will give the original DNACPR form to the patient, ambulance crew or carers in a clearly marked envelope and inform the patient’s GP and all other professionals involved in the patients care of the patients DNACPR status.
• If an ambulance is called in an emergency that is not life threatening but requires transfer to accident and emergency (A and E), for example, from an inpatient ward or patients home. The crew must be handed the care record with the DNACPR form at the front of it, or a clearly marked envelope with the original DNACPR form in. On arrival at the A and E the crew will hand formally hand-over the DNACPR form to the member of staff responsible for the patient.
• DNACR or cardiopulmonary resuscitation status must be discussed on every handover in inpatient services. All staff must be aware of the order and the reasons for the order. All staff must be aware of all patients cardiopulmonary resuscitation status, and where appropriate any DNACPR orders and the reasons for the decision. DNACPR information can also be communicated with the use of at a glance boards but must not be displayed in patient’s rooms.

The manager will be responsible for relaying the decision to the rest of the nursing team, ensuring a robust system that will cover all clinicians involved in the person’s care.

5.2.2.7 Cancellation of orders

To cancel a do not attempt cardiopulmonary resuscitation (DNACPR) order, the original form must be marked in black indelible ink with two thick diagonal lines and the word cancelled should be written across the form with the date and the signature and the name in block capitals of the clinician cancelling the form. A record of the cancellation and a rationale for this decision must be documented in the patient’s notes.

5.2.2.8 Discharge and movement

On discharge or transfer between areas, for example, outpatient appointments, any existing do not attempt cardiopulmonary resuscitation (DNACPR) order should be reviewed, and if still appropriate, communicated to all receiving teams, GP, and ambulance service if appropriate, with the original copy being sent with the patient on each journey.

The original order should be sent in an appropriately marked envelope if medical notes are not being transferred (appendix H).

5.2.2.9 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 policy 2016).

Where no decision has been made about cardiopulmonary resuscitation 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 cardiopulmonary resuscitation has been considered and recorded in advance there should be an initial presumption in favour of cardiopulmonary resuscitation. 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 cardiopulmonary resuscitation would not be successful) a carefully considered decision not to start inappropriate cardiopulmonary resuscitation should be supported” (British Medical Association, Resuscitation Council (UK), RCN 2014)

It is important to note that healthcare or nursing assistants and all other non-medical non nursing staff must commence cardiopulmonary resuscitation if a do not attempt cardiopulmonary resuscitation order is not in place.

In circumstances where cardiopulmonary resuscitation has been initiated without the knowledge of an existing DNACPR or advance decisions to refuse treatment and these documents then come to light, the continuation of cardiopulmonary resuscitation would be inappropriate however the decision to stop must come from a senior healthcare professional (nurse or doctor). If there is any doubt, cardiopulmonary resuscitation should continue until reviewed by the attending medics (paramedic or doctor).

5.2.2.10 Review of do not attempt cardiopulmonary resuscitation orders

When a do not attempt cardiopulmonary resuscitation (DNACPR) decision has been made, it is the responsibility of the medical officer signing the order to set a review date. This date will be dependant and appropriate on the nature of the order and should be set accordingly and documented on the form using one of the options:

• do not attempt cardiopulmonary resuscitation decision is to be reviewed by (specify date)
• do not attempt cardiopulmonary resuscitation decision is to remain valid until the end of life

In addition to the above all do not attempt cardiopulmonary resuscitation orders must be reviewed:

• on any change in the patient’s condition
• on admission
• prior to discharge

A record of the review must be fully documented in the patient’s notes.

As good practice in inpatient areas, do not attempt cardiopulmonary resuscitation orders should be communicated on every handover and discussed or reviewed at ward rounds and multi-disciplinary team meetings.

5.2.2.11 Rewriting of orders

Where existing orders have been found to be not valid due to record keeping errors, omissions, or damage to the form during movement etc. and rewriting the form is the most appropriate action, an entry in the patient’s notes should be made explaining the rationale of the re write. This rewrite would not necessitate a discussion with the patient or relevant others if there has been no change in the patient’s condition, therefore the date of the original discussion should be completed on the form and an entry made in the patients notes. In situations where there is no note of discussion with the patient or relevant others on the exciting form, the admitting team must ascertain the level of knowledge the patient or relevant others has, further discussion maybe needed at this stage. This discussion should be recorded in the patient’s notes, but also added to the existing form (the actual date of discussion) this addition will ensure that this conversation is not repeated during any other admissions or movements.

5.3 Child 18 years and under recommended summary plan for emergency care and treatment procedure

5.3.1 Aim

Within Rotherham Doncaster and South Humber NHS Foundation Trust (the trust) physically ill children under 18 years of age will be under the care of a consultant from a neighbouring acute trust. However, these children may be cared for within the community by trust services.

The document used to document the resuscitation status of a child under the age of 18 years is the recommended summary plan for emergency care and treatment (ReSPECT) document. Please see the ReSPECT procedure for emergency care planning and do not attempt cardiopulmonary resuscitation (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.

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 aim of this procedure is to ensure that trust colleagues are aware of their responsibilities surrounding the children and young peoples advanced care planning (CYACP) which is the children’s ReSPECT form.

The procedure aims to ensure a consistent approach for sharing the planned 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.

5.3.2 Definitions

5.3.3 Procedure

If a child within the care of the trust children’s services has an existing recommended summary plan for emergency care and treatment (ReSPECT) from within another organisation, the lead trust clinician should liaise with the child’s consultant from the other organisation, the child and their family to discuss this and to ensure that circumstances have not changed and that is still current

5.3.3.1 Communication of the order

The lead trust 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 goes with them when they are attending services, school etc.

Any child that has a child and young persons advance care plan (CYPACP) in place should have an alert added to SystmOne by the practitioner completing the recommended summary plan for emergency care and treatment (ReSPECT) trust template to alert multidisciplinary teams that the child or young person has a ReSPECT in place.

Also, the clinician should add a reminder (high priority category) stating that ReSPECT in place and where the electronic version is saved in the patient record.

The key clinician should also notify South Yorkshire Ambulance Service (YAS) for an alert to be flagged on their systems.

If the decision within the ReSPECT is that in the case of cardiopulmonary arrest that resuscitation will not take place, this needs to be clearly documented and shared with relevant parties. In the event of this decision being made the lead trust clinician will inform the trust medical director and share the ReSPECT document with them.

5.3.3.2 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 recommended summary plan for emergency care and treatment (ReSPECT) that details otherwise. Where no decision has been made about cardiopulmonary resuscitation (CPR) before any subsequent cardiopulmonary arrest, and the express wishes of the person are unknown it is expected that colleagues will attempt resuscitation.”

However, the Resuscitation Council state the below, which does allow for some senior clinical decision-making.

“Where no explicit decision about cardiopulmonary resuscitation has been considered and recorded in advance there should be an initial presumption in favour of cardiopulmonary resuscitation. 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 cardiopulmonary resuscitation would not be successful) a carefully considered decision not to start inappropriate cardiopulmonary resuscitation should be supported.” (Resuscitation Council 2021)

Is it important to note that healthcare or nursing assistants must commence cardiopulmonary resuscitation if a ReSPECT form is not in place that details that resuscitation is not to be undertaken.

In circumstances where cardiopulmonary resuscitation has been initiated without the knowledge of an existing documented decision to not resuscitate, and this form is presented the continuation of cardiopulmonary resuscitation would be inappropriate however the decision to stop must come from a senior healthcare professional (doctor or registered nurse). If there is any doubt, cardiopulmonary resuscitation should continue until reviewed by the attending paramedic or doctor.

5.3.3.3 Review of the recommended summary plan for emergency care and treatment form

The recommended summary plan for emergency care and treatment (ReSPECT) form will be reviewed when the health needs or circumstances changes, although it Is good practice to review at least annually, and should be reviewed in each person’s individual situation.

5.4 Recommended summary plan for emergency care and treatment (ReSPECT)

5.4.1 Introduction

The recommended summary plan for emergency care and treatment (ReSPECT) is a process that creates personalised recommendations for a person’s clinical care in a future emergency in which they are unable to make or express choices. It provides healthcare professionals responding to that emergency with a summary of recommendations to help them to make immediate decisions about that person’s care and treatment.

This policy details the standards, considerations, and procedures within Doncaster, relating to the initiation and journey of the ReSPECT form and process including a broad range of treatment and care decisions, particularly those relating to life sustaining treatment, including but not exclusively, cardiopulmonary resuscitation.

Many people want to be able to influence the care that they receive, and take part in decision-making about treatment, whether currently in a state of ill health, or in anticipation of future ill health. For others who lack the mental capacity to make those decisions themselves, decisions about the treatment that they receive may have to be taken by others.

This policy therefore places emphasis on the need for quality discussions by clinicians with patients, as early as possible in the patients’ journey. For example, this may be at the diagnosis of a long-term condition or when identified as entering last year of life, but this policy will have increasing relevance for people who have complex health needs, people who are likely to be nearing the end of their lives, and people who are at risk of sudden deterioration or cardiac arrest. Some people will want to record their care and treatment preferences for other reasons.

Adherence to this process supports the provision of a holistic approach which involves individual assessment, assists patients to make informed decisions and voice their preferences, to maintain the patient’s dignity, and respect of their free will.

5.4.2 What is the recommended summary plan for emergency care and treatment (ReSPECT)?

The ReSPECT form is more than a do not attempt cardiopulmonary resuscitation (DNACPR) form.

ReSPECT is a process, and its aims are to promote constructive conversations between people and their clinicians encouraging high-quality, individualised, shared decision-making with people, including in particular those who are at risk of acute deterioration, and to promote high-quality documentation of such discussions and decisions.

Advance care planning can happen at any stage and the person’s wishes, or statements may lead to a ReSPECT document being considered, discussed, and completed even in the absence of advanced illness.

This policy aims to promote emergency planning conversations between patients and clinicians as early as possible, initiated particularly for those:

• the onset of frailty or ageing
• the point of a long-term condition diagnosis
• a change or deterioration in condition

Resulting in better advanced care planning, good communication and better overall care.

Those with complex care needs and, or co-morbidities may require a detailed advanced care plan to supplement the ReSPECT documentation and to support in key decision-making in an emergency situation. Further advice on advanced care planning is provided in section 9.

5.4.3 What is a recommended summary plan for emergency care and treatment (ReSPECT) conversation?

ReSPECT conversations follow the ReSPECT process by discussing the following.

5.4.3.1 Treatment

The ReSPECT process is not solely aimed at decisions about limiting treatment; it is intended to support people to articulate and share their views about treatments and approaches to care that they do want, as well as about those that they don’t.

The process and document can cover recommendations about both specific treatments (such as clinically assisted nutrition) and approaches to care (such as whether a person would want to be taken to hospital in an emergency) with the clinician explaining sensitively advance decisions about treatments that clearly would not work in their situation.

5.4.3.2 Emergency response

This is about discussing and reaching a shared understanding of the person’s current state of health and how it may change in the foreseeable future, identifying the person’s preferences for and goals of care in the event of a future emergency and using that to record an agreed focus of care (either more towards life-sustaining treatments or more towards prioritising comfort over efforts to sustain life).

5.4.3.3 Cardiopulmonary resuscitation

Making and recording a shared decision about whether cardiopulmonary resuscitation is recommended. Decisions about whether to initiate cardiopulmonary resuscitation are one element of emergency treatment plans. Increasing evidence suggests that considering whether to attempt cardiopulmonary resuscitation and discussing cardiopulmonary resuscitation in the context of overall goals and other types of care and treatment that might be needed, reduces incidences of harm compared to focusing only on do not attempt cardiopulmonary resuscitation.

The recommended summary plan for emergency care and treatment (ReSPECT) document is intended to extend to a wider set of clinical decisions that can detail a planned system of proactive treatment and care and, or form part of an emergency response, in addition to decisions regarding cardiopulmonary resuscitation. Guidance on actual completion of the form at ReSPECT resources, Resuscitation Council UK.

Where practicably possible, the plan should stay with the person and be available immediately to health and care professionals faced with making immediate decisions in an emergency in which the person themselves has lost capacity to participate in making those decisions.

ReSPECT may be used across a range of health and care settings, including the person’s own home, an ambulance, a care home, an education setting, a hospice, or a hospital. Professionals such as ambulance crews, out-of-hours doctors, care home staff and hospital staff will be better able to make immediate decisions about a person’s emergency care and treatment if they have prompt access to agreed clinical recommendations on a ReSPECT form.

A person can still have a ReSPECT form in place and require cardiopulmonary resuscitation.

ReSPECT is not a legally binding document. It does not override clinical judgment in the event of a reversible cause of the patient’s respiratory or cardiac arrest that does not match the circumstances envisaged when the recommendation was made, provided that there is not a valid and applicable advance decision expressly refusing such intervention.

In an emergency, the presumption should be in favour of cardiopulmonary resuscitation if this has a realistic chance of prolonging life. Examples for overriding ReSPECT in favour of treatment include choking and a blocked tracheostomy.

5.4.4 Completion of a recommended summary plan for emergency care and treatment document and record-keeping

A fundamental principle of the recommended summary plan for emergency care and treatment (ReSPECT) process is that the “active” document should accompany the person in whatever healthcare setting they may be. Usually, this will require the person having the document in paper format when they are at home. A crucial aspect of ReSPECT is that it should be available to and easily accessible by the relevant healthcare professionals who may have to provide care and make immediate decisions in an emergency situation.

As the ReSPECT document is a summary of detailed conversations and planning that may have taken place on more than one occasion, it is essential that a comprehensive record of such is documented in the person’s medical record. An entry in that record should also state the date and time of completion of the ReSPECT document.

If there is a subsequent significant change in the plan of care for a person, a new ReSPECT document should be completed, and the old one clearly marked as cancelled and added to the person’s medical record. An entry should also be made in the person’s current health record stating the date and time that the document has been amended or cancelled and recording details of any new document completed. The healthcare professional with overall clinical responsibility is responsible for ensuring that this has been done.

The healthcare professional that has completed a ReSPECT document for a given person, including amending, or cancelling the document, is responsible for ensuring adequate and timely handover to other members of the healthcare team. This includes sharing electronically, where possible. All sharing of a person’s ReSPECT information should be documented clearly.

5.4.3.5 Amending or cancelling a person’s recommended summary plan for emergency care and treatment (ReSPECT) document

Following the patient’s journey, the form should be reviewed and if necessary updated if and when:

• the patient’s circumstances change (including their personal wishes and overall health)
• they have a change in care setting (Prior to discharge the content of the recommended summary plan for emergency care and treatment document, including the recommendation about cardiopulmonary resuscitation, should be reviewed, and recorded as such) (on admission and discharge from a hospital setting, admitted into a care home), see below for further information
• the responsible clinician feels it is appropriate to do so (good practice suggests every six months)

The ReSPECT document that accompanies the person on discharge should be the most recent, “active” version. The latest version document must be photocopied at discharge and be retained in the front section of the notes, the original copy accompanies the patient.

It will also be helpful to the health and care teams in the new setting (for example, GP, care home) if this information includes the relevant timescale for review of the ReSPECT document.

The ReSPECT process and summary details must be conveyed to the patient’s own GP in writing as part of the discharge summary or the discharge letter (electronically where possible). It is recommended that the GP reviews the contents of the ReSPECT form with the individual within a reasonable timeframe to ensure it remains reflective of their wishes as they recover post discharge.

A ReSPECT document should be cancelled when its contents are no longer valid, or no longer applicable. For example, this may be because the person’s clinical condition has changed; because they have requested cancellation; or because of a change in the assessment of the best interests of a person who lacks capacity.

5.4.3.6 Validity and applicability of a recommended summary plan for emergency care and treatment (ReSPECT) document

A person’s ReSPECT document will remain valid as an up-to-date plan for emergency care and potentially life-sustaining treatment until it is cancelled, or unless the decision-maker at the time has reasonable doubt that the document is not valid, or not applicable to the current situation. The decision-maker should bear in mind that they should have good reason for and be prepared to justify a decision to go against an existing ReSPECT document that is valid and applicable.

Where a patient has lost capacity for the relevant decisions, the ReSPECT document should be used as a guide to best-interests decision-making by healthcare professionals in an emergency including potentially life-sustaining treatments.

A ReSPECT document (with or without do not attempt cardiopulmonary resuscitation (DNACPR) decision) will be considered valid if it is either the original purple document, printed or photocopy and completed with a signature is either wet (penned) or the typed name of the clinician who completed the form, the clinician’s GMC or NMC number, date, role and grade must also be documented.

5.4.3.7 Recommended summary plan for emergency care and treatment for people who lack mental capacity to discuss recommendations and plans for their care and treatment in a future emergency situation

The recommended summary plan for emergency care and treatment (ReSPECT) document may be used to document recommendations for people who lack the mental capacity to discuss and make informed, shared decisions about their care. The Mental Capacity Act (2005) (MCA) sets out a legal framework of how to act and make decisions on behalf of people who lack capacity to make specific decisions for themselves and applies to people ages 16 years and over. More information on the Mental Capacity Act (2005).

Clinicians involved in the ReSPECT process should be familiar with:

• when and how to assess a person’s mental capacity
• when and how to make decisions that are in the best interests of a person who lacks capacity
• when and how to involve advocates and proxy decision-makers in relevant decisions

If a person over the age of 16 lacks mental capacity to make a particular decision under the Mental Capacity Act, any decisions regarding their treatment must be made in their best interests, unless the decision is covered by a legally valid and applicable advance decisions to refuse treatment refusing the treatment in question.

There must be involvement of:

• anyone named by the person as someone to be consulted on the matter in question or on matters of that kind
• anyone engaged in caring for the person or interested in their welfare
• any recipient of a lasting power of attorney for health granted by the person
• any deputy appointed for the person by the court unless it is not practicable or appropriate to consult them

The person’s mental capacity, lack of mental capacity, and, or the existence of a proxy decision-maker (for example, a recipient of Lasting Power of Attorney with relevant legal powers), and, or the existence of a valid and applicable ADRT should be recorded in the ReSPECT document as well as in the person’s current health record. Those with complex care needs may require an advanced care plan to supplement the ReSPECT documentation.

5.4.3.8 Roles and responsibilities for completion of the recommended summary plan for emergency care and treatment process

When embarking upon this process, all health and social care staff must:

• have accessed relevant training and education to authorise them to perform this role
• have considered and accessed the policy to clarify any concerns where relevant and, or consulted a more senior or experienced clinician or staff member
• respect the wishes of the patient wherever possible
• meet the requirements of this policy, the standards, and behaviours of an employee of their organisation and of their profession

In addition, senior clinicians (signatories) are also to:

• comply with any legally binding advance refusal of treatment including cardiopulmonary resuscitation or other life sustaining treatment, as part of an existing, valid, and applicable advance decision to refuse treatment (ADRT)
• ensure the statutory process of a best interest assessment is completed where the patient lacks capacity to be involved in the decision-making process and there is no pre-existing legally binding advance decisions to refuse treatment or specific lasting power of attorney’s with these powers
• provide benefits that are not outweighed by burden
• maintain overall responsibility for the details on the recommended summary plan for emergency care and treatment (ReSPECT) form, providing signatures, and countersignatures where applicable

5.4.3.8.1 GPs or consultants

In the community, the overall clinical responsibility for decisions in relation to recommended summary plan for emergency care and treatment, cardiopulmonary resuscitation, and details on the form, lies with the GP in charge of the patient’s care.

When a patient is admitted to hospital, the responsibility as above lies with the Consultant in charge of the patient’s care, until they’re discharged.

The GP or consultant may wish to delegate this responsibility to a suitably qualified clinician, see point 2.6.3.

5.4.3.8.2 Attendance at the accident and emergency department

In a situation where a patient experiences an acute episode resulting in an A and E attendance, the Consultant overseeing their care is responsible for ensuring that a timely request to review, and where appropriate update, the recommended summary plan for emergency care and treatment (ReSPECT) document is communicated to the GP. Clinical recommendations are encouraged as part of this communication.

5.4.3.8.3 Junior doctors

In some situations where a discussion surrounding recommended summary plan for emergency care and treatment (ReSPECT) takes place with a junior doctor with a patient, relative, carer or independent mental capacity advocate, the doctor must refer to a more senior colleague, the consultant or GP responsible for the patient’s care. Any such decision made by a junior doctor must be reviewed and countersigned by the consultant responsible for that patient at the first available opportunity prior to discharge.

5.4.3.8.4 Advanced clinicians

An advanced clinician is a suitably qualified clinician with the skills and ability to assess, diagnose and treat.

A GP or consultant may delegate the responsibility of the ReSPECT process to a suitably qualified advanced clinician. The clinician is then responsible for having a ReSPECT conversation with the patient (and, or family or carer where appropriate), completing and signing the form.

The advanced clinician must have received an appropriate level of training and be comfortable, competent, and confident in undertaking the process.

The roles and responsibilities of all staff include proactively promoting and discussing advance care planning and initiating the ReSPECT process wherever appropriate. The process itself must be carried out by a senior clinician with the correct level of training.

5.4.4 Children and young people

In Doncaster, the large majority of children needing palliative care are under the care of specialists in Sheffield or Leeds however there may be situations when clinicians within Doncaster need to initiate or complete the ReSPECT process.

5.4.4.1 Who should or could initiate the discussion, and when?

It can be appropriate for professionals caring for children and young people with life limiting or life-threatening conditions to initiate a discussion about end-of-life planning well before the child or young person is terminally ill. It may also be appropriate to begin discussions if a child or young person has an acute illness or repeated illness as a result of which it becomes clearer to professionals and, or the parents that the child or young person is moving into a terminal phase of their illness, or that they are at an increased risk of a more sudden life-threatening illness or event.

Usually, the most appropriate professional to initiate this discussion is the named paediatrician or children’s palliative care practitioner. If professionals initiate a discussion, consideration should be given to the sensitive timing of this and further support for the family and young person may be necessary.

Decision-making should not be forced on a young person or family. If a professional initiates a discussion about ReSPECT and the young person or family indicate they do not wish to continue, their wishes should be respected, and the details recorded in the medical notes.

5.4.4.2 Who can make decisions?

5.4.4.2.1 For children

Parental ability to make decisions concerning a ReSPECT for their child is governed by the Mental Capacity Act (2005).

Every effort should be made to communicate with the family in such a way that they can understand the information given and respond with their decision.

5.4.4.2.2 For young people

The Department of Health (2009) state that:

“By virtue of section 8 of the Family Law Reform Act (1969), young people aged 16 and 17 are presumed to be capable of consenting to their own medical treatment. As for adults, consent will be valid only if it is given voluntarily by an appropriately informed young person capable of consenting to the particular intervention. However, unlike adults, the refusal of a competent person aged 16 to 17 may in certain circumstances be overridden by either a person with parental responsibility or a court.”

In exceptional circumstances it may not be possible for all concerned to reach a united decision regarding the best interest of the young person. If this cannot be resolved by the patient’s consultant, the consultant should request further advice from regional experts, medical directors and legal services. Doncaster health and care services.

To establish whether a young person aged 16 or 17 has the requisite capacity to consent to the proposed intervention; the same criteria should be used as for adults. If a young person lacks capacity to consent because of an impairment of, or a disturbance in the functioning of, the mind or brain then the Mental Capacity Act (2005) will apply in the same way as it does to those who are 18 and over (Department of Health (2009).

Where a young person lacks capacity to decide, a person with parental responsibility for the young person may make a ReSPECT decision where they consider that to be in the young person’s best interests.

If a 16 or 17-year-old is capable of making an informed decision then it is not legally necessary to obtain additional consent from a person with parental responsibility. It is, however, good practice to involve the young person’s family in the decision-making process, unless the young person specifically wishes to exclude them.

5.4.4.2.3 Children in local authority care

Where a child is in the care of the local authority the child’s social worker must be involved in all of the discussions as well as parents, as the local authority shares parental responsibility with the parents. However, when a child is in voluntary care (section 20, Children Act 1989) the parents retain full parental responsibility.

5.4.4.2.4 What happens when a young person and a person with parental responsibility disagree about a recommended summary plan for emergency care and treatment decision?

Decision-making with young people may be a matter of negotiation between the child, those with parental responsibility and clinicians. Inevitably there will be times when young people and those with parental responsibility for them do not agree about whether treatment and, or do not attempt cardiopulmonary resuscitation (DNACPR) decisions should be made. If there is disagreement between the patient and those with parental responsibility despite attempts to reach agreement, legal advice should be sought.

5.4.4.2.5 What happens when medical staff and a young person or persons with parental responsibility disagree about a recommended summary plan for emergency care and treatment decision?

Where medical staff are strongly of the opinion that further treatment or cardiopulmonary resuscitation should not be attempted but the parents, young person or people with parental responsibility disagree, or vice versa, a legal opinion should be sought.

5.4.4.2.6 Safeguarding issues

Where there is doubt about whether a person with parental responsibility is acting in the interest of the child or young person, then local safeguarding children board procedures must be instigated.

5.4.5 Training and further support

In order to achieve a standardised level of training across Doncaster for all health and social care partners, there is an expectation within this policy for staff to be competent and trained in relation to recommended summary plan for emergency care and treatment in accordance with the expectation of their role.

The tiered training is as follows.

5.4.5.1 Tier one

As a minimum, this is aimed at all health and social care staff and forms part of the mandatory training to ensure staff have a general awareness of the recommended summary plan for emergency care and treatment process. Resources can be utilised from the resuscitation council website including a leaflet and the option to watch “Joe’s story video” (6 minutes).

5.4.5.2 Tier two

This is aimed at staff who are directly caring for patients for example, community nurses, practice nurses, general hospital ward nurses, and any healthcare professional in regular contact with patients who may benefit from a recommended summary plan for emergency care and treatment (ReSPECT) form. Tier two staff are expected to have an understanding of ReSPECT and this will be covered in the community life support and immediate life support training. Staff can complete the “ReSPECT awareness” module on e-learning for healthcare  and do further reading, but it is the individual’s choice.

5.4.5.3 Tier three

Tier three training is aimed at staff who will be carrying out the recommended summary plan for emergency care and treatment (ReSPECT) conversation and completing the form, for example, doctors, consultants, advanced clinicians (an advanced clinician is a suitably qualified clinician with the skills and ability to assess, diagnose and treat). It is the responsibility of each organisation to identify who is deemed appropriate to carry out the ReSPECT process and complete the forms.

The expectation is that these staff members complete the “ReSPECT authorship training” module on e-learning for healthcare and send the certificate to the trust ReSPECT lead for evidence, they will send it to learning and development for logging on ESR.

In addition, there must be a degree of flexibility across the system to share expertise, education and provide support in delivering additional tier three training in the form of workshop, table-top discussion and scenario or case base learning. Organisations are encouraged to work together across the system to ensure there is no inequity in ReSPECT education and training.

Further information and useful resources on ReSPECT for healthcare professionals, Resuscitation Council UK.

5.4.6 General principles

Variations in local policies can cause misunderstandings and lead to distressing incidents for patients, families, and staff. Increased movement of patients and staff between different care settings makes a single, integrated, and consistent approach to this complex and sensitive area a necessity. Therefore, agreement has been reached across providers to implement a single policy which applies to all multidisciplinary health and social care teams involved in patient care across Doncaster.

By working together as a system, organisations collectively acknowledge and agree to adhere to, the principles of recommended summary plan for emergency care and treatment (ReSPECT) which revolve around a desire to ensure patients get the care and outcomes they value by:

• encouraging patients to think about and communicate what outcomes they value and which ones they fear the most
• facilitating clinicians to make and record recommendations for care and treatment based on these patient preferences
• ensuring that these clinical recommendations are summarised in a plan for emergency care and treatment
• ensuring that the recommendations are recognised and respected by pre-hospital, primary and secondary care

5.4.7 Commitment from organisations

Organisations who agree to adhere to this policy also commit to the following:

• ensuring all staff access the most appropriate level of education and training to enable us to embed the ReSPECT process or conversation within the system
• to raise awareness of the ethos of ReSPECT and the importance of early conversations, documenting, and sharing those outcomes and updating appropriately
• identify a ReSPECT champion within their own organisation to become part of a local ReSPECT champion network that will meet quarterly to drive and further embed ReSPECT within the system
• to ensure education and quality improvement in relation to the details on the ReSPECT form are a priority and that concerns regarding quality are raised via an appropriate platform to allow the system to work collaboratively to resolve in a supportive manner
• to work as one health and social care system by ensuring effective communication across organisations in relation to ReSPECT forms and shared decision-making for the best interest of the patient
• where necessary and appropriate, carry out those difficult conversations, and provide patients with the information they need to make decisions about their care Doncaster health and care services working in partnership across Doncaster
• continue to explore digital options in alignment with the Doncaster place digital strategy
• acknowledge that ReSPECT recommendations can only be effective across healthcare settings if they are correctly completed and shared without delay with relevant healthcare professionals whose decisions it is intended to inform

5.4.8 Organisations that agree to delivering the strategy within this policy

• Doncaster Clinical Commissioning Group.
• Doncaster Metropolitan Borough Council.
• Rotherham Doncaster and South Humber NHS Foundation Trust.
• Primary Care Doncaster.
• Doncaster Local Medical Committee.
• Doncaster and Bassetlaw Teaching Hospitals.
• Flyde Coast Medical Services, Doncaster.
• Age UK Doncaster.
• Yorkshire Ambulance Service.

6 Training implications

In adherence with the expectations of the Resuscitation Council UK, all staff should have basic knowledge and skills in resuscitation. All staff should be equipped to recognise cardiac arrest, to commence cardiopulmonary resuscitation (CPR) and call for help. All staff should attend, as a minimum, community life support (CLS) every 12 months.

All registered nurses, doctors, and nursing assistants working in areas where physical restraint, rapid tranquilisation or seclusion may be required, will be trained to a level equal to the immediate life support (ILS) course of the Resuscitation council UK. This will be repeated every 12 months.

All registered nurses and nursing assistants working within areas with immediate access to a defibrillator will be trained to the equal level of the immediate life support course of the Resuscitation Council UK. This will be repeated every 12 months.

When practicable and appropriate, the training will be contextual, and scenario based. Staff who do not successfully complete the training assessments will be recalled within 1 month for further training. Failure to complete the assessments after 3 attempts will be discussed with the manager by the resuscitation service.

Basic training on do not attempt cardiopulmonary resuscitation (DNACPR) and recommended summary plan for emergency care and treatment (ReSPECT) will be within the community life support and immediate life support sessions. For clinicians who have such discussions within their job roles (includes some specialist nurses identified in the Resuscitation Committee), additional training is required (see DNACPR and ReSPECT sections)

The Yorkshire and Humber e-learning is an excellent source of information and can be used as a training resource in team meetings. It can also be used as an individual training resource and can be found on the trust eLearning platform.

6.1 All non-clinical and community clinical staff community life support training (includes do not attempt cardio-pulmonary resuscitation or recommended summary plan for emergency care and treatment)

• How often should this be undertaken: 12 months.
• Length of training: 3 hours.
• Delivery method: face to face.
• Training delivered by whom: resuscitation service.
• Where are the records of attendance held: electronic staff record (ESR).

6.2 All in-patient clinical staff immediate life support (ILS) training

• How often should this be undertaken: 12 months.
• Length of training: 3 hours.
• Delivery method: face to face.
• Training delivered by whom: resuscitation service.
• Where are the records of attendance held: electronic staff record (ESR).

6.3 Clinicians that have escalation plan discussions in care groups that have recommended summary plan for emergency care and treatment: e-learning

• How often should this be undertaken: one-off.
• Length of training: 40 minutes.
• Delivery method: e-learning, ReSPECT.
• Training delivered by whom: Resuscitation Council UK.
• Where are the records of attendance held: electronic staff record (ESR).

6.4 Clinicians that have escalation plan discussions in care groups that have recommended summary plan for emergency care and treatment

• How often should this be undertaken: one off and more if required.
• Length of training: 1 hour.
• Delivery method: face to face clinical supervision for additional sessions.
• Training delivered by whom: nurse consultant in palliative care. consultants in older peoples mental health.
• Where are the records of attendance held: electronic staff record (ESR).

6.5 For care groups that do not have the recommended summary plan for emergency care and treatment document

Clinician completing do not attempt cardiopulmonary resuscitation (DNACPR) decisions, see link above.

• How often should this be undertaken: one off.
• Length of training: 1 hour.
• Delivery method: e-learning.
• Where are the records of attendance held: electronic staff record (ESR).

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as:

• all user emails for urgent messages
• one to one meetings or supervision
• continuous professional development sessions
• posters
• daily email (sent Monday to Friday)
• practice development days
• group supervision
• special meetings
• intranet
• team meetings
• local induction

7 Monitoring arrangements

7.1 Policy implementation

• Policy implementation including:
  • requirement for a documented plan for vital signs monitoring that identifies which variables need to be measured, including the frequency of measurement
  • use of an early warning system within the trust to recognise patients at risk of deterioration
  • actions to be taken to minimise or prevent further deterioration in patients
  • how the trust documents that resuscitation equipment is checked, stocked and fit for use
  • incident reports of resuscitation events
  • incident reports of choking situation events
  • staff training, as identified in the training needs analysis
• How: resuscitation audit.
• Who by: resuscitation officer.
• Reported to: quarterly and annually.
• Frequency: Resuscitation Committee.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

There are no additional requirements in relation to privacy, dignity and respect.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Links to any other associated documents

• Consent to care and treatment policy
• Clinical risk assessment and management policy
• Clinical skills policy
• Incident management policy
• Infection prevention and control
• Mandatory and statutory training policy
• Mental Capacity Act (2005) policy
• Medical devices management policy
• Slips, trips and falls for staff and visitors, prevention and management policy
• Rapid tranquillisation policy and guidelines (pharmacological management of violence)

10 References

• Resuscitation Council (UK) (2021) resuscitation guidelines
• Guidance, do not attempt cardiopulmonary resuscitation (DNACPR) and cardiopulmonary resuscitation (CPR) decisions
• Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), Resuscitation Council UK
• Mental Capacity Act (2005)
• Advance decisions to refuse treatment guide
• Advance care planning, end of life care, Royal College of Nursing

11 Appendices

11.1 Appendix A Resuscitation Committee terms of reference

11.1.1 Name of committee or group

Resuscitation Committee.

11.1.2 Purpose

The purpose of this Resuscitation Committee is to review the trust’s assurance processes for resuscitation and to oversee the annual audit work plan taking into account UK Resuscitation Council Quality Standards.

11.1.3 Membership

The membership of the group would include:

• medical director (chair)
• nurse consultant, St John’s Hospice (deputy chair)
• lead learning and development facilitator, mandatory and statutory training
• chief pharmacist or a nominated deputy
• head of patient safety
• clinical representation from each care group as determined by the relevant associate nurse director
• medical representative
• allied health professional representative
• patient governor representative
• non-executive director

11.1.4 Attendance

All members, or a nominated deputy, from each care group should attend each meeting. Each care group representative should have a clinical background. In addition, other directors, senior managers and advisors will be invited to attend as and when required. Attendance will be recorded in the minutes of each meeting.

11.1.5 Quoracy

The chair or deputy chair and a clinical representative from each care group should be present. The senior clinical representative will be determined by the associate nurse director from each care group.

11.1.6 Meeting arrangements (frequency, chair, venue, administrative support arrangements)

Meetings shall be held 3 monthly. Administrative support will be provided by the executive medical director’s personal assistant.

11.1.7 Key responsibilities or objectives or duties or powers

These key responsibilities (KR) will be represented in the agenda responsibilities of the Resuscitation Committee as defined by the Resuscitation Council (UK) include:

• KR 1, ensuring implementation and adherence to national resuscitation guidelines and standards
• KR 2, defining the role and composition of the resuscitation team
• KR 3, ensuring that resuscitation equipment for clinical use is available and ready for use
• KR 4, ensuring that appropriate resuscitation drugs (including those for peri-arrest situations) are available and ready for use
• KR 5, planning adequate provision of training in resuscitation
• KR 6, determining requirements for and choice of resuscitation training equipment
• KR 7, preparing and implementing policies relating to resuscitation and treatment of anaphylaxis
• KR 8, preparing and implementing policies relating to prevention of cardiac arrest
• KR 9, preparing and implementing a policy on resuscitation decisions, (for example, do not attempt cardiopulmonary resuscitation (DNACPR) decisions), and advance care planning (this is usually in collaboration with palliative care teams)
• KR 10, quality improvement, action plans based on audits, for example, review of audit data using National Cardiac Arrest Audit data for benchmarking
• KR 11, recording and reporting of patient safety incidents in relation to resuscitation
• KR 12, the Resuscitation Committee is responsible for implementing operational policies governing cardiopulmonary resuscitation, practice and training

An annual audit report will provide assurance against each of the above key responsibility areas and will include relevant audit data.

11.1.8 Receipt of minutes and reports from

Completed resuscitation audits and any other relevant clinical audits undertaken.

11.1.9 reporting arrangements

Quality Committee for assurance in relation to the key responsibilities outlined in section 7 via an annual resuscitation report.

Safety and quality operational group.

The Executive Management team for any issues that require an urgent executive operational response.

Involvement of a designated non-executive director will have oversight of, and will sit as part of, the Resuscitation Committee.

11.1.10 Date

Each year.

11.1.11 Review date

Each year.

11.1.12 Document owner or responsibility for review (lead director)

Executive medical director.

11.2 Appendix B the deteriorating patient

Refer to appendix B: the deteriorating patient (staff access only).

11.2.1 Appendix B1 new head injury flow chart

1. Immediately perform an DRABC (danger, response, airway, breathing, circulation) assessment and assess for red flags (see list of red flags below).
2. Complete neuro observations, NEWS and full ABCDE assessment.
3. See neuro observation and NEWS2 chart guidelines (on reverse of the charts) for use.

If patient is breathing examine for injury, if none found, get patient up using appropriate techniques.

If injury found provide appropriate first aid.

11.2.1.1 If red flag signs or symptoms

If red flags signs or symptoms call 2222 or (9)999 for an emergency ambulance immediately.

1. Continue neuro observations and NEWS at least every 15 minutes until ambulance arrives, ensure SBAR handover ready for paramedic.
2. Paramedic to complete GCS arrival.

11.2.1.1.1 List of red flags

• Unconsciousness or lack of full consciousness (post injury) for example, problems keeping eyes open.
• Problems understanding, speaking, reading, or writing (post injury).
• Loss of feeling in part of the body (post injury).
• Problems balancing or walking (post injury).
• General weakness (post injury).
• Any changes in eyesight.
• Any clear fluid running from ears or nose.
• A black eye with no obvious damage around the eye.
• Bleeding from one or both ears.
• New deafness in one or both ears.
• Bruising behind one or both ears.
• Any evidence of scalp or skull damage, especially when the skull has been penetrated.
• A forceful blow to the head at speed.
• A seizure since the injury.
• Amnesia for events before or after the injury (problems with memory) change from normal presentation.
• Any vomiting episodes since the injury.
• Any previous cranial neurosurgical interventions (brain surgery), history of bleeding or clotting disorder.
• Current anticoagulant therapy (NICE (CG176) states for patients (adults and children) who have sustained a head injury with no other indications for a computerised tomography (CT) head scan and who are having anticoagulant treatment, perform a CT head scan within 8 hours of the injury (there will be times when this is not considered as clinically beneficial for the patient, for example, patient in the last days of life, a medical review and rationale for not performing a CT head must be documented)).
• Current drug or alcohol intoxication.
• Irritability or altered behaviour (easily distracted, not themselves, no concentration, no interest in things around them) change from normal presentation.

11.2.1.2 If no red flags but other changes

If no red flags but other changes (see list of other changes below)

11.2.1.2.1 Patient presentation

1. Must instigate call to clinician (usually a medical doctor but in some areas this function can be carried out by other designated clinical staff, for example, nurse consultants).
2. Request urgent visit.
3. Continue neuro observations and NEWS at least every 15 minutes until clinicians examination.

11.2.1.2.2 List of other changes

• Any previous loss of consciousness (knocked out) because of the injury, from which the injured person has now recovered.
• Persistent headache since the injury.
• Age 65 years or older.
• Suspicion of non-accidental injury.
• Continuing concern by the professional about the diagnosis or presentation.

11.2.1.2.3 If no red flags and no other changes

Continue neuro observations at least:

• half hourly for 2 hrs
• then hourly for 4 hrs
• then 2 hourly until NEWS or neuro observations at baseline
• must be reviewed by an appropriate clinician (NICE (CG176) states for patients (adults and children) who have sustained a head injury with no other indications for a computerised tomography (CT) head scan and who are having anticoagulant treatment, perform a CT head scan within 8 hours of the injury (there will be times when this is not considered as clinically beneficial for the patient, for example, patient in the last days of life, a medical review and rationale for not performing a CT head must be documented))
• within 24 hours who will also complete Glasgow Coma Scale (GCS)
  on wards where GCS is part of existing practice GCS to be completed by ward staff
• if neuro observations and NEWS are as baseline at initial reading continue observations for at least 6 hours post event

Continue to monitor for red flags (as these can take longer to present).

Any new signs or symptoms should be escalated immediately.

11.2.2 Appendix B2 ligature flow chart

1. Ligature found around a patient’s neck, call for help (use walkie talkie or activate alarm if available).
2. Request emergency equipment and ligature cutter.
3. Assess, approach patient from the front when safe to do so.

11.2.2.1 Suspected strangulation

11.2.2.1.1 Complete, body suspended by ligature from a fixed point

1. Hold patient at thighs or hips and raise slightly to reduce tension on ligature.
2. After tension on ligature is reduced and with assistance to support weight of patient, safely remove or cut ligature between anchor point and knot. Lay patient supine and cut ligature from neck.
3. Qualified nurse to assess, perform DRABC assessment, assess for “RED FLAGS” (see list of red flags below) and undertake full set of neuro observations and NEWS2. Protect c-spine and use jaw thrust to open airway if airway is compromised.

11.2.2.1.2 Incomplete, body is not suspended entirely via a ligature

1. Hold patient at torso and raise slightly to reduce tension on ligature.
2. After tension on ligature is reduced and with assistance to support weight of patient, safely remove or cut ligature between anchor point and knot. Lay patient supine and cut ligature from neck.
3. Qualified nurse to assess, perform DRABC assessment, assess for “RED FLAGS” (see list of red flags below) and undertake full set of neuro observations and NEWS2. Protect c-spine and use jaw thrust to open airway if airway is compromised.

11.2.2.2 Lying strangulation (body is on the floor at low level anchor point)

Slide patient up towards ligature to reduce tension and safely remove or cut ligature.

Qualified nurse to assess, perform DRABC assessment, assess for red flags (see list of red flags below) and undertake full set of neuro observations and NEWS2. Protect c-spine and use jaw thrust to open airway if airway is compromised.

11.2.2.3 Unsuspended strangulation

If torso is not under any ligature pressure, continue to safely remove or cut ligature.

Qualified nurse to assess, perform DRABC assessment, assess for “RED FLAGS” (see list of red flags below) and undertake full set of neuro observations and NEWS2. Protect c-spine and use jaw thrust to open airway if airway is compromised.

11.2.2.4 Red flags

• Resuscitation required.
• Suspected neck fracture.
• Difficulty or painful swallowing.
• Crepitus or subcutaneous crepitus (air under skin with crackling or crunchy feeling to touch).
• Tenderness over hyoid bone.
• Any loss of consciousness.
• Deeply indented ligature mark.
• A long period of ligature Cyanosis (blue lips and skin) not subsiding immediately after ligature removal.
• Sweating or clamminess.
• Continued coughing.
• Petechial haemorrhages (small red marks with pinpoint centres on eyes, face, neck or lips).
• Suffocation when sticking out tongue.
• Persistent breathlessness or hoarseness since ligature incident.

Call ambulance for transfer to accident and emergency or emergency department or urgent and emergency care centre

11.2.2.5 No red flags

11.2.2.5.1 National early warning score 2 (NEWS2) above baseline or any other concern

Call doctor or other designated clinician (ANP, ACP, physician associate).

Clinician review within 2 hours to undertake history and physical examination including assessment of:

• patency of airway
• breathing
• swallowing
• neurological system

Reassess for red flags. Review frequency and duration of ongoing physical observations

11.2.2.5.2 National early warning score 2 (NEWS2) at baseline and no other concerns

Monitor:

• neuro observations and national early warning score 2 (NEWS2)
• every 15 minutes for 1 hour
• every 20 minutes for next
• 3 hours (minimum)

Over next 36 hours, be alert for the emergence of:

• confusion
• sweating
• tender larynx
• mild cough
• wheezing hypoxia
• Swelling of the neck
• rapid breathing or shortness of breath
• muffled or hoarse voice
• fast and, or irregular pulse rate
• motor or sensory loss

Seek medical review if signs emerge or as indicated by NEWS2 or neuro observations.

11.2.3 Appendix B3 normal parameter exception care plan

Refer to appendix B3: normal parameter exception care plan (staff access only).

11.3 Appendix C emergency drugs

Refer to appendix C: emergency drugs (staff access only).

11.4 Appendix D emergency equipment

Refer to appendix D: emergency equipment (staff access only).

11.4.1 Appendix D1 equipment checklist

Refer to appendix D1: grab bag checklist (staff access only).

11.4.2 Appendix D2 equipment checklist

Refer to appendix D2: equipment checklist (staff access only).

11.5 Appendix E cardiac arrest report form

Refer to appendix E: cardiac arrest report form (staff access only).

11.6 Appendix F young people aged 16 and 17 years special considerations

Some special considerations apply where patients are aged 16 or 17 years.

11.6.1 Current practice relating to young persons

The Association for Children’s Palliative Care (2004) recommends that every young person with a life limiting condition should be helped, with their family, to decide on an end of life or palliative care plan.

Within the trust, the large majority of children (16 to 18 years) needing palliative care are under specialists in Sheffield.

11.6.2 Who should or could initiate discussion, and when?

It can be appropriate for professionals looking after young people with life limiting or life threatening conditions to initiate discussion about end of life planning well before the young person is terminally ill. It may also be appropriate to begin discussions if a young person has an acute illness or repeated illness as a result of which it becomes clearer to professionals and, or the parents that the young person is moving into a terminal phase of their illness, or that they are at an increased risk of a more sudden life threatening illness or event. Usually the most appropriate professional to initiate this discussion is the named paediatrician or palliative care practitioner.

If professionals initiate discussion, consideration should be given to the sensitive timing of this and further support for the family and young person may be necessary. Decision-making should not be forced on a young person or family. If a professional initiates a discussion about do not attempt cardio pulmonary resuscitation (DNACPR) and the young person or family indicate they do not wish to continue, their wishes should be respected, and the details recorded in the young person’s medical record.

Discussion may also be initiated by the young person or family at any time.

11.6.3 Who can make decisions?

The Department of Health (2009) state that:

“By virtue of section 8 of the Family Law Reform Act (1969), young people aged 16 and 17 are presumed to be capable of consenting to their own medical treatment. As for adults, consent will be valid only if it is given voluntarily by an appropriately informed young person capable of consenting to the particular intervention. However, unlike adults, the refusal of a competent person aged 16 to 17 may in certain circumstances be overridden by either a person with parental responsibility or a court”

In exceptional circumstances it may be impossible for all concerned to reach a united decision regarding the best interest of the young person. If this cannot be resolved by the patient’s consultant, the consultant should request further advice from regional experts, trust medical director and trust legal services department.

To establish whether a young person aged 16 or 17 has the requisite capacity to consent to the proposed intervention, the same criteria should be used as for adults. If a young person lacks capacity to consent because of an impairment of, or a disturbance in the functioning of, the mind or brain then the Mental Capacity Act (2005) will apply in the same way as it does to those who are 18 and over (Department of Health (2009)).

Where a young person lacks capacity to decide, a person with parental responsibility for the young person may make a DNACPR decision where they consider that to be in the young person’s best interests.

If a 16 or 17 year-old is capable of making an informed decision then it is not legally necessary to obtain additional consent from a person with parental responsibility. It is, however, good practice to involve the young person’s family in the decision-making process, unless the young person specifically wishes to exclude them, if the young person consents to their information being shared.

If a young person decides that he or she does not wish to be resuscitated and that the family should not be involved with or informed about the decision this must be urgently referred to the trust medical director and legal services department.

11.6.4 What is, and who has, parental responsibility?

Parental responsibility is defined by section 3 of the Children Act (1989) as:

“All rights, duties, powers, responsibilities and authority which by law a parent of a child has in relation to a child and his property.”

Parental responsibility is therefore concerned with bringing the child up, caring for him and making decisions about him, including the right to consent or withhold consent for medical treatment. Parental responsibility is relinquished on a young person’s eighteenth birthday.

The Children Act (1989) sets out persons who may have parental responsibility. These include:

• the child’s mother
• the child’s father, if he was married to the mother at the time of birth
• unmarried fathers, who can acquire parental responsibility in several different ways:
  • for children born before 1 December 2003, unmarried fathers will have parental responsibility if they:
    • marry the mother of their child or obtain a parental responsibility order from the court
    • register a parental responsibility agreement with the court or by an application to court
  • for children born after 1 December 2003, unmarried fathers will have parental responsibility if they:
    • register the child’s birth jointly with the mother at the time of birth
    • re-register the birth if they are the natural father
    • marry the mother of their child or obtain a parental responsibility order from the court
    • register with the court for parental responsibility
    • the child’s legally appointed guardian
    • a person in whose favour the court has made a residence order concerning the child
    • a local authority designated in a care order in respect of the child
    • a local authority or other authorised person who holds an emergency protection order in respect of the child.
  • it should be noted that:
    • if a child is in local authority care parents can share parent responsibility with the local authority, this is lost if the child is adopted
    • parental responsibility can also be restricted by a court order
    • foster parents do not automatically have parental responsibility

11.6.5 Children in local authority care

Where a child is in the care of the local authority the child’s social worker must be involved in all of the discussions as well as parents, as the local authority shares parental responsibility with the parents. However, when a child is in voluntary care (section 20, Children Act (1989)) the parents retain full parental responsibility.

11.6.5.1 What happens when a young person and a person with parental responsibility disagree about a do not attempt cardiopulmonary resuscitation decision?

Decision-making with young people may be a matter of negotiation between the child, those with parental responsibility and clinicians. Inevitably there will be times when young people and those with parental responsibility for them do not agree about whether a do not attempt cardiopulmonary resuscitation (DNACPR) decision should be made.

If a young person is deemed to have the capacity to make a DNACPR decision (or believes he or she has capacity to make a decision?) and there is disagreement between the patient and those with parental responsibility despite attempts to reach agreement, legal advice should be sought.

What happens when medical staff and a young person or persons with parental responsibility disagree about a DNACPR decision?

Where medical staff are strongly of the opinion that cardiopulmonary resuscitation should not be attempted but the young person or people with parental responsibility disagree, or vice versa, a legal opinion should be sought.

11.6.6 Safeguarding issues

Where there is doubt about whether a person with parental responsibility is acting in the interest of the young person, then local safeguarding children board procedures must be instigated.

11.6.7 Education establishments

Potentially a young person may wish to continue at school with an agreed do not attempt cardiopulmonary resuscitation (DNACPR) decision in place. This can potentially cause anxieties for both the family and staff supporting that young person. Advice can be sought from a palliative care practitioner in dealing with those anxieties and what measures can be put in place to support the child and family during this period.

11.6.8 Interface with the child death overview process

Each safeguarding board has a designated paediatrician for all unexpected child deaths who are supported by a Rapid Response team. All deaths of a person under 18 years of age must be reported to the rapid response professional in the local area, who will notify the child death overview panel of the local safeguarding children board in accordance with the statutory guidance in chapter 7, Working Together to Safeguard Children 2010. Do not attempt cardiopulmonary resuscitation (DNACPR) status must be reported at this time. The rapid response team contact details can be found on the local safeguarding children’s board website.

11.7 Appendix G cardio-pulmonary resuscitation decision-making framework

1. Is cardiac or respiratory arrest a clear possibility?
   • No, it is not necessary to discuss cardiopulmonary resuscitation with the patient unless they express a wish to discuss it
2. Yes, is there a realistic change that cardiopulmonary resuscitation could be successful?
   • No, if a do not attempt cardiopulmonary resuscitation (DNACPR) decision is made on clear clinical grounds that cardiopulmonary resuscitation would not be successful there should be a presumption in favour of informing the patient of the decision and explaining the reason for it (see section 5). Subject to appropriate respect for confidentiality those close to the patient should also be informed and offered an explanation. Where the patient lacks capacity and has a welfare attorney or court-appointed deputy or guardian, this representative should be informed of the decision not to attempt cardiopulmonary resuscitation and the reasons for it as part of the ongoing discussion about the patient’s re (see section 5). If the decision is not accepted by the patient, their representative or those close to them, a second opinion should be offered
3. Yes, does the patient lack capacity and have an advance decision specifically refusing cardiopulmonary resuscitation or have an appointed attorney, deputy or guardian?
   • Yes, if a patient has made an advance decision refusing cardiopulmonary resuscitation, and the criteria for applicability and validity are met, this must be respected. If an attorney, deputy or guardian has been appointed they should be consulted (see sections 9.1 and 10).
4. No, does the patient lack capacity?
   • Yes, discussion with those close to the patient must be used to guide a decision in the patient’s best interests (see section 10). When the patient is a child or young person, those with parental responsibility should be involved in the decision where appropriate, unless the child objects (see section 11).
5. No, is the patient willing to discuss his or her wishes regarding cardiopulmonary resuscitation?
   • No, respect and document their wishes (see section 6.3). Discussion with those close to the patient may be used to guide a decision in the patient’s best interests, unless confidentiality restrictions prevent this.
6. Yes, the patient must be involved in deciding whether cardiopulmonary resuscitation will be attempted in event of cardiorespiratory arrest.
   • If cardiorespiratory arrest occurs in the absence of a recorded decision there should be an initial presumption in favour of attempting cardiopulmonary resuscitation.
   • Anticipatory decisions about cardiopulmonary resuscitation are an important part of high-quality health care for people at risk of death or cardiorespiratory arrest.
   • Decisions about cardiopulmonary resuscitation are sensitive and complex and should be undertaken by experienced members of the healthcare team with appropriate competence.
   • Decision about cardiopulmonary resuscitation require sensitive and effective communication with patients and those close to patient.
   • Decision about cardiopulmonary resuscitation must be documented fully and carefully.
   • Decisions should be review with appropriate frequency and when circumstances change.
   • Advice should be sought if there is uncertainty.

Taken from Resuscitation Council UK, British Medical Association and Royal College of Nursing (2016) Decisions relating to cardiopulmonary resuscitation. 3rd.

11.8 Appendix H do not attempt cardiopulmonary resuscitation form (WZT652)

Refer to appendix H: do not attempt cardiopulmonary resuscitation form (WZT652) (staff access only).

11.9 Appendix I do not attempt cardiopulmonary resuscitation communication sticker

Refer to appendix I: do not attempt cardiopulmonary resuscitation communication sticker (staff access only).

11.10 Appendix J What if my heart stops leaflet

This leaflet has been produced to help you understand what happens when your heart stops beating, how cardio-pulmonary resuscitation (CPR) can be used, and when it may not be helpful.

It may be upsetting to talk about resuscitation. This booklet tries to explain the issues as clearly and sensitively as possible.

You do not have to discuss resuscitation if you do not want to. However your health care team is available if you change your mind.

11.10.1 Why do people die?

It’s sad, but everybody dies.

Thinking about dying usually makes us sad, and perhaps a bit frightened.

It’s not something we like to think about, but talking with your family or with your doctor, and making plans for that time, can make things as easy as possible for you and those close to you.

Death might be due to an accident, or a sudden event, but most people die from serious illnesses which they have had for many months or even years.

11.10.2 What happens when my heart stops beating?

When you die your heart stops beating.

No blood gets pumped round your body, so very quickly the rest of your body stops working.

Your kidneys, your liver, your lungs all stop working.

Your brain will stop working about three minutes after your heart stops beating.

11.10.3 What is cardiopulmonary resuscitation?

If your heart stops beating it may be possible to start it beating again.

Attempts to restart your heart will include pressing down firmly on your chest again and again, and breathing for you.

This is called cardiopulmonary resuscitation (CPR).

Ambulance or hospital staff might use a machine to give your heart an electric shock to make it start working again.

They may put a tube down your windpipe to help you breathe, or give you drugs to help your heart start.

11.10.4 Do patients fully recover after cardiopulmonary resuscitation?

Each person has a different chance of cardiopulmonary resuscitation (CPR) working. Only about 2 out of 10 patients who have cardiopulmonary resuscitation survive and go home from hospital; survival is less likely in people with lots of health problems.

Even if cardiopulmonary resuscitation starts the heart again, patients usually need more treatment, often in an intensive care unit. Some patients never get fully better and suffer from mental or physical disabilities.

The decision to attempt cardiopulmonary resuscitation has nothing to do with how old you are or your abilities. It is about whether the treatment will help you.

Your doctor is the best person to decide if cardiopulmonary resuscitation is likely to help.

Cardiopulmonary resuscitation will not be attempted if it will only start your heart and breathing for a short time, or if it would prolong your suffering.

11.10.5 Will someone discuss cardiopulmonary resuscitation with me?

You might want to talk about what happens when you die, or you might have questions about cardiopulmonary resuscitation. It might be that because you have lots of health problems, cardiopulmonary resuscitation cannot help, and the health care team will decide not to attempt it when your heart stops. This is a do not attempt cardiopulmonary resuscitation (DNACPR) decision.

You have a right to be told if a DNACPR decision has been made, unless telling you would be harmful.

11.10.6 What if I don’t want to or am unable to talk about this myself?

You can appoint someone to have power of attorney for your health. This person is then allowed to speak on your behalf when you can’t do this yourself. If you cannot talk for yourself or don’t wish to, then the health care professionals in charge of your care will decide what treatment is best for you (this is a best interests decision). Wherever possible they will discuss this with those close to you.

11.10.7 What if I want cardiopulmonary resuscitation to be attempted?

Health care professionals will not refuse your wish for cardiopulmonary resuscitation (CPR) if it will be of benefit to you.

However, you cannot insist on having a treatment that will not work. Health care professionals will not offer treatment that will be degrading or cause harm.

If there is any doubt that cardiopulmonary resuscitation would work, the health care team can arrange a second opinion if you would like one.

If cardiopulmonary resuscitation might work, but it is likely to leave you severely ill or disabled, your opinion about whether the chances are worth taking is very important.

The health care team must and will listen to your.

11.10.8 What if I know I don’t want to be resuscitated?

If you don’t want cardiopulmonary resuscitation you can refuse it and your health care team must respect your wishes. You can talk to your doctor or nurse about this.

Your doctor or nurse can give you advice on making a legally binding advance decision to refuse treatment.

11.10.9 If it is decided cardiopulmonary resuscitation will not be attempted, what will happen next?

If you do not want cardiopulmonary resuscitation (CPR), or if your doctor decides that it will not work for you, a do not attempt cardiopulmonary resuscitation (DNACPR) form will be completed and discussed with you.

It tells everyone who looks after you that this decision has been made.

There is only one copy of the form which will be needed if you are admitted to hospice or hospital, or if you travel by ambulance. At home, it needs to be kept safe so that healthcare professionals can see it if needed.

11.10.10 What happens if my situation changes?

Your do not attempt cardiopulmonary resuscitation (DNACPR) form will state when the decision should be reviewed. If your health condition changes, the decision can be reviewed.

Your health care team will be happy to discuss any changes with you.

11.10.11 Can I see what is written about me?

You have a legal right to see what is written about you and can ask to do so.

If you do not understand what is written, your health care team will explain it to you.

11.10.12 What about other treatments?

If doctors decide not to attempt cardiopulmonary resuscitation, this will not affect any of your other treatment.

You will still receive the best care and medicines for your condition.

11.10.13 Who else can I talk to about this?

If you or your family do not think that you have had a chance to talk about this properly, please talk to a nurse or doctor looking after you.

If you don’t want to talk about it at all, that’s fine too.

There are people to listen if and when you do:

• your family, friends and carers
• a hospital chaplain, or someone from your own faith community
• an advocacy service
• community nursing teams
• palliative care teams
• your GP
• your district nurse

This leaflet has been adapted from an original collaboration between The Bradford and Airedale Palliative Care Managed Clinical Network for People with Learning Disabilities and Bradford Taking Media’s Access to Information for Minorities (AIM) Project.

The Yorkshire and Humber DNACPR Regional Working Group gratefully acknowledges the work of these groups.

11.10.14 References and further reading

The Bradford and Airedale palliative care managed clinical network for people with learning disabilities

Phone: 01274 323 511

Bradford Talking media

11 to 12 Eldon Place
Bradford
BD1 3AZ

• Phone: 01274 848 150
• Bradford Talking Media

11.10.15 Document control

Decisions relating to cardiopulmonary resuscitation, Royal College of Nursing, Resuscitation Council (UK), British Medical Association 3rd edition 2014 Deciding right, your life your choice. NHS England Northern Clinical Networks and Senate, April 2014.

11.11 Appendix K where to document the do not attempt cardio-pulmonary resuscitation decision in the electronic records

1. Search for DNACPR in templates or locate RDaSH DNACPR in the left-hand clinical tree under corporate templates.
2. Right click on RDaSH DNACPR.
3. Click again on RDaSH DNACPR.
4. The green information box will come up.
5. Click the grey DNACPR tab at the top.
6. This page gives a guide to DNACPR. The grey tab goes to the page to be completed, see next page.
7. Tick the relevant boxes.
8. Select the correct action from the drop-down menu, for example, not for attempted cardiopulmonary resuscitation.
9. Write the details of the conversation with the patient or those closest to them, or the review on an existing document in the “detail of information” box.
10. If having a review date, tick the box.
11. If valid until the end of life, tick the box.
12. Press OK and Save as normal.

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Document control

• Version: 1.4.
• Unique reference number: 629.
• Approved by: clinical effectiveness group.
• Date approved: 13 May 2025.
• Name of originator or author: resuscitation officer.
• Name of responsible committee or individual: chief nurse.
• Date issued: 11 August 2025.
• Review date: 31 October 2025.
• Target audience: all staff.

Page last reviewed: November 18, 2025
Next review due: November 18, 2026

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