DNAR (Do Not Attempt Resuscitation): Policy, Practice and Challenges (Presentation at Dublin Community Network Meeting / Residential Network Meeting, November 2016)

1. DNAR
Policy, Practice and Challenges

2. 'Do not resuscitate': Ide’s plea for
wishes to be respected. 80 year old
woman's fear of being "hammered to
hell" by paramedics is terrifying her in
her final years. ‘I want to be a happy
camper when I leave this world’
Irish Examiner

3. Think About
Are there times when I know resuscitation
or attempted resuscitation shouldn’t have
happened but it did?
Have I ever discussed DNAR with a
resident?
What needs to happen in my nursing
home/hospital?

4. Guidance/Policies:
• National Consent Policy 2012 - Part 4 – DNAR
Other Guidance
• Medical Council Guidelines
• An Bord Altranais
• Local policies
Pending
• National Policy On Do‐not‐attempt‐resuscitation
Decisions

5. 28/11/2013National Consent Policy
National Consent Policy (HSE)
• Provides a decision-making framework to facilitate
advance discussion of personal preferences
regarding CPR and DNAR orders
• Aims to ensure decisions are made consistently,
transparently and in line with best practise

6. 28/8/2013 National Consent Policy
General Principles
• Individual decision-making
• Involving individuals in discussions
• Involving family & friends in discussions
• Decision-making capacity
• Provision of information
• Decision-making regarding CPR & DNAR orders

7. 28/11/2013National Consent Policy
Terminology : What do we mean by…
DNAR: Do Not Attempt Resuscitation (CPR)
CPR: Cardiopulmonary Resuscitation includes chest
compressions, defibrillation, the injection of drugs &
ventilation of lungs

8. 28/11/2013National Consent Policy
Cardiopulmonary Resuscitation
• Intervention for treatment of cardiorespiratory arrest
• Survival rates:
• In hospital: 13-20%
• Out of hospital: lower again
• Includes:
• Chest compressions
• Defibrillation
• Medication
• Ventilation

9. Why should we talk about DNAR?
• Fits with the practice of good care planning
• Having conversations about DNAR and future care
provision results in better care at end of life.
• Protects the patient from unnecessary and
inappropriate interventions
• In keeping with individuals right to refuse (ADMCA
2015)
• Avoids ‘slow coding’ and ‘sham resuscitation’
• Prevents confusion and unnecessary distress to
families
Talkcpr clip

10. National Consent Policy
Individual decision-making
• Individual assessment of each case
• Individual's own views and values are central
• Balance benefits and risks involved in CPR and likelihood of
success
• Likely clinical outcome
• Likelihood of successfully restarting heart and breathing
for a sustained period
• Level of recovery that can be reasonably expected

11. Involving Family
• If the person wishes..
• If the person wants…
• If the person can’t participate…
•Find out from those who know the person best about any
previously expressed preferences wishes and beliefs.
•From their knowledge of the person ,what do they think the
person would want.. This does not mean that they make
the choice or decision.
The final decision regarding DNAR lies with the most senior
healthcare professional

12. Let’s discuss
1. Are there residents currently in my care who would
benefit from this conversation?
2. Are there residents in my care who cannot engage
in this conversation but for whom this decision
should be made?
3. What, if anything, is needed in my nursing
home/hospital to enhance practice in this area?

13. Talking about dying
• http://www.sad.scot.nhs.uk/video-wall/

14. Cheers!