Recording and promoting
good decision-making
The Emergency Care and Treatment Plan
Dr David Pitcher
Vice President
Resuscitation Council (UK)
Author / co-author / contributor on this topic:
National guidance: Decisions relating to cardiopulmonary resuscitation
ABC of Resuscitation
European Society of Cardiology eLearning: Acute Cardiac Care
ALS Course Manual
Resuscitation Council (UK) Resuscitation Guidelines
Led intervention by RC (UK) in the Court of Appeal 2014
Led development of RC (UK) model DNACPR form 2008/9
Co-chair of ETCP Working Group
No financial conflicts of interest
Good decision-making
Where are we starting from?
Where have we got to?
Where are we going?
Where are we starting from?
If I wanted to get there, I wouldn’t start from here
Decisions to withhold CPR

Considering
 Discussing
 Recording
are challenging
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 Misunderstandings
 Poor decision-making
 Communication failures
are common
Difficulties for everyone
• conversations about death and dying
• changing emphasis: from prolonging life to
ensuring comfort
• conversations that focus on withholding
treatment seen as potentially life-saving.
NCEPOD – in-hospital cardiac arrest
2011
• Only 22% had a recorded decision about CPR
but physiological instability/warning signs in 73%
• Many elderly, potentially fatal chronic conditions,
limited functional capacity
• In 196/230 expert advisors felt DNACPR decisions
warranted
• CPR attempted in 52 with DNACPR decisions and 7 on
end-of-life care pathways
Court of Appeal 2014
“...presumption in favour of patient involvement...”
...anecdotal reduction in DNACPR decisions...
...but surely leaving someone ‘for CPR’
when they may not want it is also a breach
of their human rights...
October 2014
“…there are clear benefits in having
(CPR) decisions recorded on standard
forms that are … recognised across
geographical and organisational
boundaries within the UK.”
Royal Society of Medicine - October 2014
DNACPR
from
best evidence
to
best policy and practice
Emergency Care and Treatment Plan
• Development of a national document and process
• Facilitated by the RC (UK) and RCN
• Broad stakeholder and public/patient engagement
• Working group - met first February 2015
Health Select Committee March 2015
‘… we recommend that the
government review the use of
DNACPR orders…including
whether resuscitation decisions
should be considered in the
context of overall treatment plans.
…there is a case for standardising
the recording mechanisms for the
NHS in England.’
A new document
on its own will not
change behaviour,
but…
A new document
on its own will not
change behaviour,
but…
Some key features
•
•
•
•
•
•
Promote good decision-making
Encourage more conversations
Identify priorities/goals of care
Promote good recording
Used across all care settings
For individuals of all ages
A change of culture
Emergency Care and Treatment Plan
Record summary information
and reasons for the chosen plan
Emergency Care and Treatment Plan
Identify overall priorities for
care and treatment
Emergency Care and Treatment Plan
Record decisions about:
• what would be wanted if needed
• what would not be wanted
• what will not work
Record details of other
care-planning documents
Emergency Care and Treatment Plan
Record decision
whether or not to attempt CPR
Conversations about CPR
More acceptable if they:
• occur in the broader context of a person’s
priorities for their care and treatment
• include decisions to attempt CPR
Emergency Care and Treatment Plan
Ensure that decisions comply with capacity
legislation
Confirm when and with whom decisions
have been discussed – and if not, why not
Signature of clinician completing the ECTP
Signature of senior responsible clinician
Details of emergency contacts
If a treatment will not work…
…it
should not be offered
People cannot use an ECTP to demand
treatment that is not being offered
Doctors do not have to seek consent to
withhold treatment that is not offered
(because it will not work)
…but using these statements in a
conversation with a patient will be unhelpful
When treatment will not work…
…involve the patient:
Explain decisions and the reasons
for them in a sensitive way…
…in the context of their priorities
When treatment might work…
…make shared decisions
When people lack capacity:
Good decision-making
Each decision must be based on each
individual’s situation
Every decision must be:
• free from any discrimination
• guided by the quality of future life that the
individual would regard as acceptable
Good decision-making
•
•
•
•
•
Recognise when a decision may be appropriate
Plan ahead – avoid having to decide in a crisis
Inform and involve people in decisions
Communicate effectively with all – check understanding
Document decisions, discussions and reasons
Recognising who may need an ECTP
Long-term condition
Admission to hospital
Increasing frailty
Disability
Approaching the end of life
ADRT or advance directive
Who should start
a conversation about ECTP?
The person best able to support the
patient/family because they:
• know them well
• have good communication skills
Shared decisions
Require:
• people to be well enough
• time to consider carefully
• time to discuss fully
Make explicit decisions
when they are needed
Don’t delay a decision:
• because a person is not well enough to have it explained
• because family/representatives are not available
Make/record a plan to explain/discuss/review decisions
In summary:
• Involve the patient – make shared decisions
• Involve those important to the patient – support
• Involve other members of the healthcare team
The senior responsible clinician carries the
ultimate responsibility for good decision-making
Where are we going?
Consultation/usability
Piloting
Implementation
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What will it involve?
Everyone
Commitment
Time
Perseverance
Where are we going?
Better, safer
care and
treatment
42
Are we nearly there yet?
A dynamic document and process that is
responsive to feedback and continues to evolve
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