The document outlines guidelines from the Indian Council of Medical Research (ICMR) on 'Do Not Attempt Resuscitation' (DNAR). It defines DNAR as relating only to cardiopulmonary resuscitation and not to other treatments. The guidelines state that DNAR may be appropriate for patients with progressive, debilitating, or terminal illnesses where CPR would be non-beneficial or prolong suffering. Treating physicians should discuss DNAR with patients or surrogates and ensure informed consent is obtained. The final decision regarding DNAR rests with the treating physician.
The document discusses the goals of implementing a new Goals of Patient Care (GOPC) form across hospitals in Western Australia to improve end-of-life care and decision making. It provides background on the form's trial implementation at various sites. The new form aims to have goals of care discussions with patients or their surrogates to determine appropriate treatment based on probable outcomes, not just resuscitation status. It outlines the form's structure with sections on baseline information, goal of care selection, discussion summary, and extended use. The document emphasizes improving communication around goals of care and ensuring treatment aligns with patients' values and preferences.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
This document provides recommendations for minimum standards of care for out-of-hospital cardiac arrest (OHCA) management by prehospital services in Malaysia. It outlines standards for ambulance dispatch centers to identify suspected OHCA and provide dispatch-assisted CPR instructions. It recommends a minimum of three responders be dispatched to the scene and that all responders be competent in basic life support with advanced life support teams able to perform additional interventions like defibrillation or needle decompression. The document also provides criteria for transporting or terminating resuscitation of OHCA patients in the prehospital setting based on factors like the presence of bystander CPR, shockable rhythms, or return of spontaneous circulation.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
This seminar covered delayed transfers of care from hospital, a Mental Capacity Act/DoLS landscape update and claims arising from Human Rights Act 1998.
The document discusses trauma teams and their roles. It defines a trauma team as a multidisciplinary group that works together to assess and treat severely injured patients. A team approach has been shown to significantly reduce resuscitation times compared to individual doctors. The roles of trauma team members are outlined, as well as techniques for effective communication, briefing, handover, and speaking up if concerns arise. Statistics from Western Australia in 2015 show the most common causes of death for major trauma patients were head injuries and brain death. Overall mortality rates were lower than the national average.
DNAR (Do Not Attempt Resuscitation): Policy, Practice and Challenges (Present...Irish Hospice Foundation
DNAR (Do Not Attempt Resuscitation): Policy, Practice and Challenges (Presentation at Dublin Community Network Meeting / Residential Network Meeting, November 2016)
The document outlines guidelines from the Indian Council of Medical Research (ICMR) on 'Do Not Attempt Resuscitation' (DNAR). It defines DNAR as relating only to cardiopulmonary resuscitation and not to other treatments. The guidelines state that DNAR may be appropriate for patients with progressive, debilitating, or terminal illnesses where CPR would be non-beneficial or prolong suffering. Treating physicians should discuss DNAR with patients or surrogates and ensure informed consent is obtained. The final decision regarding DNAR rests with the treating physician.
The document discusses the goals of implementing a new Goals of Patient Care (GOPC) form across hospitals in Western Australia to improve end-of-life care and decision making. It provides background on the form's trial implementation at various sites. The new form aims to have goals of care discussions with patients or their surrogates to determine appropriate treatment based on probable outcomes, not just resuscitation status. It outlines the form's structure with sections on baseline information, goal of care selection, discussion summary, and extended use. The document emphasizes improving communication around goals of care and ensuring treatment aligns with patients' values and preferences.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
This document provides recommendations for minimum standards of care for out-of-hospital cardiac arrest (OHCA) management by prehospital services in Malaysia. It outlines standards for ambulance dispatch centers to identify suspected OHCA and provide dispatch-assisted CPR instructions. It recommends a minimum of three responders be dispatched to the scene and that all responders be competent in basic life support with advanced life support teams able to perform additional interventions like defibrillation or needle decompression. The document also provides criteria for transporting or terminating resuscitation of OHCA patients in the prehospital setting based on factors like the presence of bystander CPR, shockable rhythms, or return of spontaneous circulation.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
This seminar covered delayed transfers of care from hospital, a Mental Capacity Act/DoLS landscape update and claims arising from Human Rights Act 1998.
The document discusses trauma teams and their roles. It defines a trauma team as a multidisciplinary group that works together to assess and treat severely injured patients. A team approach has been shown to significantly reduce resuscitation times compared to individual doctors. The roles of trauma team members are outlined, as well as techniques for effective communication, briefing, handover, and speaking up if concerns arise. Statistics from Western Australia in 2015 show the most common causes of death for major trauma patients were head injuries and brain death. Overall mortality rates were lower than the national average.
DNAR (Do Not Attempt Resuscitation): Policy, Practice and Challenges (Present...Irish Hospice Foundation
DNAR (Do Not Attempt Resuscitation): Policy, Practice and Challenges (Presentation at Dublin Community Network Meeting / Residential Network Meeting, November 2016)
The document discusses patient assessment for emergency medical responders. It covers performing a scene size-up to ensure safety and identify hazards. The primary assessment involves evaluating a patient's level of consciousness, airway, breathing, and circulation to identify life threats. A medical history is then obtained. The secondary assessment is a more thorough examination of all body systems to locate and treat non-life threatening injuries or illnesses. Vital signs including respiration, pulse, and capillary refill are assessed. Reassessment of the patient periodically is also recommended.
PEGS, palliation and planning: Issues in caring for people with advanced MSMS Trust
This document discusses issues related to palliative care and advance care planning for people with advanced multiple sclerosis. It provides an overview of palliative care approaches, the legal and ethical basis for palliation and planning, and specific palliative issues in MS. It also covers topics like advance decisions to refuse treatment, common issues with writing advance refusal documents, and what to do when faced with an advance care plan. The objectives are to understand challenges with advance care planning and outline specific issues regarding planning in MS.
Triage is the process of prioritizing patients according to the urgency of their need for care. It aims to ensure patients are treated in order of clinical urgency and receive timely care. There are three main types of triage - primary triage in the field, secondary triage in the emergency department, and tertiary triage by specialists. The START and SAVE methods are used for disaster triage in the field to categorize patients into immediate, delayed, or minimal care/expectant groups. In the ED, patients are assigned colors based on their condition - red for most urgent, yellow intermediate, green less urgent, and black for deceased. Documentation, equipment, and designated triage teams are needed to properly conduct triage
This document discusses disaster surgery and mass casualty incidents. It defines mass casualty incidents as those involving hundreds of casualties that strain local hospital capacity. Disasters can be natural, like earthquakes, or man-made, like accidents or terrorist attacks. When they produce more patients than initial responders can handle, triage is critical to sort patients into categories based on need. The goal of triage is to minimize loss of life by providing the most urgent care first. Fundamental steps in management include assessing airway, breathing, circulation, disability and exposure to stabilize patients.
This document defines a new bio-medical-psycho-social construct called prolonged dying phase (PDP). PDP occurs when a terminally ill patient's dying process exceeds expected or communicated prognoses, causing suffering related to perceptions of time. PDP can stem from erroneous prognoses, multiple conflicting predictions, or acceptance of an indefinite timeline. Both subjective factors like memory and objectively prolonged deaths from interventions also contribute. The construct aims to better understand suffering at the end of life related to perceptions of how long the dying process may take.
Prehospital care in trauma is as important as in hospital care. The presentation addresses simple and basic approach to care a polytrauma victim in platinum 10 minutes based on BTLS.
Triage in emergency department 100121135547-phpapp01-170528183022abdul mannan
Triage is the process of sorting patients based on the urgency of their condition to provide the right care to the patients who need it most. It involves an initial assessment of patients upon arrival to identify life-threatening issues and prioritize patients into categories based on need. The document outlines the goals and categories of triage in both emergency and disaster situations, with categories ranked from resuscitation to non-urgent based on the threat to life, limb, or function. It also describes the key components of triage including an initial across-the-room assessment and ongoing re-assessments to manage patient flow efficiently and address needs as conditions may change.
This document provides information on triage systems and procedures. It defines triage as sorting patients based on treatment priority. The START and JumpSTART triage systems categorize patients as red/immediate, yellow/delayed, green/minor, or black/deceased based on their respiration, pulse, and mental status. It outlines how to rapidly assess and tag patients in a mass casualty event using these criteria in 3 sentences or less per patient to maximize survivability. The document recommends clearing walking patients first and prioritizing life-saving interventions for immediate patients before movement or additional treatment.
The assessment, diagnosis and treatment of critically ill patients is extremely challenging. Patients often deteriorate whilst being
reviewed and their rapidly changing pathophysiology barrages healthcare professionals with new data. Furthermore, comprehensive assessments must be postponed until the patient has been stabilised. So, important data and interventions are often missed in the heat of the moment. In emergency situations, suboptimal management decisions may cause signifi cant morbidity and mortality. Fortunately, standardisation and careful design of documentation (i.e. proformas and checklists) can enhance patient safety. So, I have developed a series of checklist proformas to guide the assessment of critically ill patients. These proformas also promote the systematic recording and presentation of information to facilitate the retrieval of the precise data required for the management for critically ill patients. The proformas have been modifi ed extensively over the last twenty years based on my personal experience and extensive consultation with colleagues in several world-renowned centres of excellence. The proformas were originally developed for use in the intensive therapy unit
or high dependency unit. However, they have been adapted for use by outreach teams reviewing patients admitted outside of critical care areas. The use of these tools can direct eff orts to provide appropriate organ support and provides a framework for diagnostic reasoning.
This document discusses advance care planning and advance directives. It defines key terms like advance directives, living wills, durable power of attorney for healthcare, Do Not Resuscitate orders, palliative care, hospice care, and comfort care. It explains the importance of advance care planning and having conversations with loved ones about end-of-life wishes. However, it notes that many people do not complete advance directives due to lack of knowledge, difficulties with paperwork, and potential family disagreements. The document provides resources for individuals to learn more about advance care planning.
S12 Solutions is a mobile application and website created to make Mental Health Act (MHA) assessment setup and claim form processes quicker, simpler and more secure. To understand the impact of the S12 Solutions platform locally, Wessex AHSN have undertaken an independent evaluation on behalf of the Hampshire and the Isle of Wight Sustainability and Transformation Partnership (HIOW STP).
This document discusses mass casualty management and disaster preparedness for hospitals. It provides data on road traffic accidents in Nepal and describes key aspects of managing mass casualty incidents, including establishing triage, conducting primary and secondary surveys, and activating disaster plans. The main points are:
1) Triage is crucial to prioritize patients and direct them to the appropriate level of care. The START method is described.
2) During primary survey, life threats like airway, breathing, and circulation are addressed within 2-5 minutes.
3) Secondary survey thoroughly examines all body systems to identify minor injuries.
4) Hospitals must have clear disaster plans, adequate staff and supplies, and policies to handle surges
When to start and stop CPR and resuscitation efforts in cases of out-of-hospital cardiac arrest (OHCA) is an important ethical issue that involves balancing patient preferences, medical futility, and legal requirements. Guidelines recommend not starting or terminating resuscitation based on criteria such as lack of witness, no response to initial efforts, and presence of a do-not-resuscitate order. Exceptions may include traumatic arrest, hypothermia, or reversible causes where continued efforts may be beneficial.
Pre-hospital care aims to reduce morbidity and mortality for patients outside the hospital by providing immediate medical care at the scene and during transport. It involves various providers like paramedics, nurses, and doctors who are specially trained to treat patients in pre-hospital settings. The philosophy is to intervene appropriately and transport patients safely to definitive care in a timely manner. An effective pre-hospital care system requires coordination between various stakeholders including emergency responders, hospitals, and policymakers to ensure patients receive optimal care from the scene to the hospital.
The document discusses mass casualty incidents (MCIs) and lessons learned from past events. It defines MCIs and different levels based on severity. The philosophy of care shifts from individuals to the greatest number in MCIs. Past events like Gallant Eagle and Beirut demonstrated the importance of coordination, triage, and evacuation. The Tokyo sarin gas attack showed limitations of emergency responders and need for improved communication and cooperation between agencies.
This lesson covers key principles for safely managing patients at an emergency scene and during transport. It emphasizes:
1) Ensuring safety, assessing scene needs and identifying life threats as top priorities.
2) Properly managing airway, breathing, circulation and disability to stabilize the patient.
3) Rapidly extricating and transporting patients to the appropriate facility while communicating clearly with staff.
The document summarizes the student's observation of the trauma center at Abilene Regional Hospital. It describes various medical cases seen including abdominal pain, chest pain, and injuries from an automobile accident. It discusses the goals of triage in the trauma center to prioritize patients based on need. It also outlines safety guidelines followed in the trauma center including security protocols and monitoring systems. Finally, it describes the critical role of trauma nurses in providing fast, knowledgeable care under stressful conditions to stabilize patients and prevent further health deterioration.
The document provides information on key concepts in emergency nursing. It defines emergency care and the concept of emergency nursing. It outlines the scope and principles of emergency nursing practice. These include establishing airway and ventilation, controlling hemorrhage, and conducting thorough assessments. The document also discusses principles of emergency management, triage, common emergencies like airway obstruction and hemorrhage, and how to manage injuries such as wounds, abdominal trauma, and heat stroke.
The document describes the Sentinel system, a systematic approach to early recognition of drowning developed by lifeguards in New Zealand. Sentinel stratifies drowning risk into 5 statuses based on behaviors and symptoms, with Status 1 indicating an immediate threat to life. It provides guidance on detection, response, and care needed at each status. An early pilot study found lifeguards using Sentinel criteria could detect a Status 1 scenario 75% of the time within 30 seconds. Further research is still needed to fully validate the model.
End of life Resources Used at Nenagh Hospital (Poster at HFH Conference 2016)Irish Hospice Foundation
A mass is held annually at St. John's Church to remember patients who died at Nenagh Hospital in the previous year. Families are invited and a candle is lit for each deceased person. The hospital also provides training to staff on end-of-life care called "Final Journeys" and over 70 staff have attended. Initiatives to improve end-of-life care at the hospital include annual remembrance masses, staff training, creating a family room, and using symbols and items to provide respect and solemnity during the end-of-life process and after death.
The document discusses patient assessment for emergency medical responders. It covers performing a scene size-up to ensure safety and identify hazards. The primary assessment involves evaluating a patient's level of consciousness, airway, breathing, and circulation to identify life threats. A medical history is then obtained. The secondary assessment is a more thorough examination of all body systems to locate and treat non-life threatening injuries or illnesses. Vital signs including respiration, pulse, and capillary refill are assessed. Reassessment of the patient periodically is also recommended.
PEGS, palliation and planning: Issues in caring for people with advanced MSMS Trust
This document discusses issues related to palliative care and advance care planning for people with advanced multiple sclerosis. It provides an overview of palliative care approaches, the legal and ethical basis for palliation and planning, and specific palliative issues in MS. It also covers topics like advance decisions to refuse treatment, common issues with writing advance refusal documents, and what to do when faced with an advance care plan. The objectives are to understand challenges with advance care planning and outline specific issues regarding planning in MS.
Triage is the process of prioritizing patients according to the urgency of their need for care. It aims to ensure patients are treated in order of clinical urgency and receive timely care. There are three main types of triage - primary triage in the field, secondary triage in the emergency department, and tertiary triage by specialists. The START and SAVE methods are used for disaster triage in the field to categorize patients into immediate, delayed, or minimal care/expectant groups. In the ED, patients are assigned colors based on their condition - red for most urgent, yellow intermediate, green less urgent, and black for deceased. Documentation, equipment, and designated triage teams are needed to properly conduct triage
This document discusses disaster surgery and mass casualty incidents. It defines mass casualty incidents as those involving hundreds of casualties that strain local hospital capacity. Disasters can be natural, like earthquakes, or man-made, like accidents or terrorist attacks. When they produce more patients than initial responders can handle, triage is critical to sort patients into categories based on need. The goal of triage is to minimize loss of life by providing the most urgent care first. Fundamental steps in management include assessing airway, breathing, circulation, disability and exposure to stabilize patients.
This document defines a new bio-medical-psycho-social construct called prolonged dying phase (PDP). PDP occurs when a terminally ill patient's dying process exceeds expected or communicated prognoses, causing suffering related to perceptions of time. PDP can stem from erroneous prognoses, multiple conflicting predictions, or acceptance of an indefinite timeline. Both subjective factors like memory and objectively prolonged deaths from interventions also contribute. The construct aims to better understand suffering at the end of life related to perceptions of how long the dying process may take.
Prehospital care in trauma is as important as in hospital care. The presentation addresses simple and basic approach to care a polytrauma victim in platinum 10 minutes based on BTLS.
Triage in emergency department 100121135547-phpapp01-170528183022abdul mannan
Triage is the process of sorting patients based on the urgency of their condition to provide the right care to the patients who need it most. It involves an initial assessment of patients upon arrival to identify life-threatening issues and prioritize patients into categories based on need. The document outlines the goals and categories of triage in both emergency and disaster situations, with categories ranked from resuscitation to non-urgent based on the threat to life, limb, or function. It also describes the key components of triage including an initial across-the-room assessment and ongoing re-assessments to manage patient flow efficiently and address needs as conditions may change.
This document provides information on triage systems and procedures. It defines triage as sorting patients based on treatment priority. The START and JumpSTART triage systems categorize patients as red/immediate, yellow/delayed, green/minor, or black/deceased based on their respiration, pulse, and mental status. It outlines how to rapidly assess and tag patients in a mass casualty event using these criteria in 3 sentences or less per patient to maximize survivability. The document recommends clearing walking patients first and prioritizing life-saving interventions for immediate patients before movement or additional treatment.
The assessment, diagnosis and treatment of critically ill patients is extremely challenging. Patients often deteriorate whilst being
reviewed and their rapidly changing pathophysiology barrages healthcare professionals with new data. Furthermore, comprehensive assessments must be postponed until the patient has been stabilised. So, important data and interventions are often missed in the heat of the moment. In emergency situations, suboptimal management decisions may cause signifi cant morbidity and mortality. Fortunately, standardisation and careful design of documentation (i.e. proformas and checklists) can enhance patient safety. So, I have developed a series of checklist proformas to guide the assessment of critically ill patients. These proformas also promote the systematic recording and presentation of information to facilitate the retrieval of the precise data required for the management for critically ill patients. The proformas have been modifi ed extensively over the last twenty years based on my personal experience and extensive consultation with colleagues in several world-renowned centres of excellence. The proformas were originally developed for use in the intensive therapy unit
or high dependency unit. However, they have been adapted for use by outreach teams reviewing patients admitted outside of critical care areas. The use of these tools can direct eff orts to provide appropriate organ support and provides a framework for diagnostic reasoning.
This document discusses advance care planning and advance directives. It defines key terms like advance directives, living wills, durable power of attorney for healthcare, Do Not Resuscitate orders, palliative care, hospice care, and comfort care. It explains the importance of advance care planning and having conversations with loved ones about end-of-life wishes. However, it notes that many people do not complete advance directives due to lack of knowledge, difficulties with paperwork, and potential family disagreements. The document provides resources for individuals to learn more about advance care planning.
S12 Solutions is a mobile application and website created to make Mental Health Act (MHA) assessment setup and claim form processes quicker, simpler and more secure. To understand the impact of the S12 Solutions platform locally, Wessex AHSN have undertaken an independent evaluation on behalf of the Hampshire and the Isle of Wight Sustainability and Transformation Partnership (HIOW STP).
This document discusses mass casualty management and disaster preparedness for hospitals. It provides data on road traffic accidents in Nepal and describes key aspects of managing mass casualty incidents, including establishing triage, conducting primary and secondary surveys, and activating disaster plans. The main points are:
1) Triage is crucial to prioritize patients and direct them to the appropriate level of care. The START method is described.
2) During primary survey, life threats like airway, breathing, and circulation are addressed within 2-5 minutes.
3) Secondary survey thoroughly examines all body systems to identify minor injuries.
4) Hospitals must have clear disaster plans, adequate staff and supplies, and policies to handle surges
When to start and stop CPR and resuscitation efforts in cases of out-of-hospital cardiac arrest (OHCA) is an important ethical issue that involves balancing patient preferences, medical futility, and legal requirements. Guidelines recommend not starting or terminating resuscitation based on criteria such as lack of witness, no response to initial efforts, and presence of a do-not-resuscitate order. Exceptions may include traumatic arrest, hypothermia, or reversible causes where continued efforts may be beneficial.
Pre-hospital care aims to reduce morbidity and mortality for patients outside the hospital by providing immediate medical care at the scene and during transport. It involves various providers like paramedics, nurses, and doctors who are specially trained to treat patients in pre-hospital settings. The philosophy is to intervene appropriately and transport patients safely to definitive care in a timely manner. An effective pre-hospital care system requires coordination between various stakeholders including emergency responders, hospitals, and policymakers to ensure patients receive optimal care from the scene to the hospital.
The document discusses mass casualty incidents (MCIs) and lessons learned from past events. It defines MCIs and different levels based on severity. The philosophy of care shifts from individuals to the greatest number in MCIs. Past events like Gallant Eagle and Beirut demonstrated the importance of coordination, triage, and evacuation. The Tokyo sarin gas attack showed limitations of emergency responders and need for improved communication and cooperation between agencies.
This lesson covers key principles for safely managing patients at an emergency scene and during transport. It emphasizes:
1) Ensuring safety, assessing scene needs and identifying life threats as top priorities.
2) Properly managing airway, breathing, circulation and disability to stabilize the patient.
3) Rapidly extricating and transporting patients to the appropriate facility while communicating clearly with staff.
The document summarizes the student's observation of the trauma center at Abilene Regional Hospital. It describes various medical cases seen including abdominal pain, chest pain, and injuries from an automobile accident. It discusses the goals of triage in the trauma center to prioritize patients based on need. It also outlines safety guidelines followed in the trauma center including security protocols and monitoring systems. Finally, it describes the critical role of trauma nurses in providing fast, knowledgeable care under stressful conditions to stabilize patients and prevent further health deterioration.
The document provides information on key concepts in emergency nursing. It defines emergency care and the concept of emergency nursing. It outlines the scope and principles of emergency nursing practice. These include establishing airway and ventilation, controlling hemorrhage, and conducting thorough assessments. The document also discusses principles of emergency management, triage, common emergencies like airway obstruction and hemorrhage, and how to manage injuries such as wounds, abdominal trauma, and heat stroke.
The document describes the Sentinel system, a systematic approach to early recognition of drowning developed by lifeguards in New Zealand. Sentinel stratifies drowning risk into 5 statuses based on behaviors and symptoms, with Status 1 indicating an immediate threat to life. It provides guidance on detection, response, and care needed at each status. An early pilot study found lifeguards using Sentinel criteria could detect a Status 1 scenario 75% of the time within 30 seconds. Further research is still needed to fully validate the model.
End of life Resources Used at Nenagh Hospital (Poster at HFH Conference 2016)Irish Hospice Foundation
A mass is held annually at St. John's Church to remember patients who died at Nenagh Hospital in the previous year. Families are invited and a candle is lit for each deceased person. The hospital also provides training to staff on end-of-life care called "Final Journeys" and over 70 staff have attended. Initiatives to improve end-of-life care at the hospital include annual remembrance masses, staff training, creating a family room, and using symbols and items to provide respect and solemnity during the end-of-life process and after death.
'Dying in Acute Hospitals - Care Experiences From the Perspectives of Bereave...Irish Hospice Foundation
'Dying in Acute Hospitals - Care Experiences From the Perspectives of Bereaved Relatives' by Bettina Korn and Diarmuid O Coimin (Presentation at HFH 2016 Conference)
The document outlines the Irish Hospice Foundation's strategic plan for 2013-2016. It identifies three key outcomes: 1) prioritizing palliative care for people with dementia across all care settings, 2) improving end-of-life care for older people in residential care facilities, with a focus on those with dementia, and 3) increasing public awareness of death and dying to encourage early advance care planning, including for those with dementia. The plan details the tools, resources, education and advocacy efforts that will be undertaken to achieve these outcomes over the three year period.
This document discusses an initiative by the Yeats Country Quilters group to donate handmade quilts to the paediatric unit of Sligo University Hospital. The quilts are given to bereaved parents of children who have passed away as a gift of comfort and support. Nursing staff sensitively offer the quilts to parents during the difficult time of their child's death. The initiative has provided compassion and support to grieving parents and has received recognition awards. It demonstrates community spirit and partnership in caring for families experiencing loss.
'HSC Bereavement Network - Celebrating 10 years' (Poster at HFH 2016 Conference)Irish Hospice Foundation
The HSC Bereavement Network was established in 2006 to improve bereavement care in Northern Ireland. Over the next 10 years, the Network worked to establish 6 standards of care and conducted audits and engagement activities. This resulted in new regional policies, training programs, and resources to support bereaved individuals and healthcare staff. Going forward, the Network aims to further raise awareness of available guidance and support, update relevant strategies, and monitor the implementation of best practices for bereavement care across health trusts.
National Standards for Bereavement Care following Pregnancy Loss and Perinata...Irish Hospice Foundation
This document outlines national standards for bereavement care following pregnancy loss and perinatal death in Ireland. It was developed through extensive consultation with healthcare professionals and bereaved families. The standards cover bereavement care across different types of pregnancy loss and perinatal outcomes. They address care areas like diagnosis, information provision, support services, staff training, and multi-disciplinary bereavement teams. The standards aim to establish a framework to guide compassionate and consistent bereavement care nationwide.
Presentation on DNAR Policy (From Acute Hospital Network, June 2014) [AHN 19]Irish Hospice Foundation
This document discusses DNAR (Do Not Attempt Resuscitation) policies and communication regarding end-of-life care. It notes that while DNAR policies aim to provide guidance, individual decision making is needed. DNAR decisions should be made through open discussions involving the patient and considering their prognosis, values and goals. However, communication challenges can arise from unrealistic expectations, denial, misunderstandings and conflicts. The document advocates clear documentation and communication of DNAR decisions across care settings to ensure patient wishes are followed.
Legal and ethical issues in critical care nursingNursing Path
This document discusses several key ethical and legal issues faced by critical care nurses, including informed consent, use of restraints, end-of-life decisions around life-sustaining treatment, organ donation, and resolving ethical problems. It outlines important ethical principles like autonomy, beneficence, and justice. It also addresses issues like medico-legal cases, documentation, and the most concerning ethical issues reported by nurses.
Presentation on Advance Healthcare Directives (From Acute Hospital Network, J...Irish Hospice Foundation
The document discusses proposed legislation in Ireland to establish a legal framework for advance healthcare directives (AHDs). Key points:
- AHDs would allow people to make healthcare decisions in advance if they lose capacity in the future, promoting autonomy and respecting personal values and choices.
- To be valid, an AHD must be in writing, made voluntarily by those with capacity, and witnessed. People can also appoint a healthcare representative.
- AHDs can refuse treatments but not basic care. Refusals must clearly specify treatments and circumstances. Life-sustaining refusals require additional verification.
- The legislation aims to comply with international standards while not affecting laws on euthanasia or
Do Not Resuscitate Orders : What They Mean ?SMSRAZA
Most doctors working in Acute areas know when and how to do CPR. However, most get stuck when it comes to ' When not to do CPR' due to cultural, social, ethical and legal issues attached.
This document discusses advance healthcare directives (AHDs) in Ireland. It notes that only 6% of people in Ireland have written an AHD. It defines AHDs as documents where a person can write down medical treatments they do not want if they lose decision-making capacity. For an AHD to be legally binding, the person must have had capacity when writing it and it must apply to their current medical situation. The document outlines the requirements for making a valid AHD in Ireland and implications for healthcare professionals, including that they have no liability for complying with a valid AHD or not complying if there are doubts about its validity.
This document provides guidance on obtaining valid consent and assessing mental capacity. It discusses the importance of ensuring patients understand procedures and risks before obtaining consent. It outlines key principles from the Mental Health Act and Mental Capacity Act, such as assessing capacity and determining best interests. The document also describes types of consent forms, roles like IMCA advocates, and powers like LPAs. It includes examples of how to quantify and qualify risks to patients. Finally, it provides answers to sample cases related to valid consent and mental capacity.
This document provides information about advanced directives. It defines an advanced directive as a legal document that specifies a person's wishes for medical treatment if they become unable to make decisions. It discusses the importance of advanced directives for patients, families, and physicians. It also describes different types of advanced directives like living wills, medical powers of attorney, and do not resuscitate orders.
- Nurses in critical care settings often face complex ethical dilemmas related to caring for critically ill patients. These dilemmas are exacerbated by advanced medical technologies that can prolong life.
- When considering decisions around life-sustaining treatments like CPR, withholding or withdrawing care, nurses must ensure the decisions are guided by patients' values and preferences to respect patient autonomy. However, patient autonomy is still a weak concept in India where family often makes decisions.
- Proper documentation of medical care and informed consent are important for ethical and legal reasons. Restraints should only be used as a last resort to prevent harm and the least restrictive method possible.
This guide is designed to help health and social care professionals understand and implement the law relating to advance decisions to refuse treatment (ADRT) contained in the Mental Capacity Act (2005).
This 2013 version replaces that published in September 2008 and covers:
How to make an advance decision to refuse treatment, who can make an advance decision, when a decision should be reviewed and how it can changed or withdrawn
What should be included
Rules applying to advance decisions to refuse life sustaining treatment and how they relate to other rules about decision-making
How to decide on the existence, validity and applicability of advance decisions and what healthcare professionals should do if an advance decision is not valid or applicable
The implications for healthcare professionals of advance care decisions, including situations where a healthcare professional has a conscientious objection to stopping or providing life-sustaining treatment
What happens if there is a disagreement about an advance decision.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
This document discusses the key ethical issues surrounding cardiopulmonary resuscitation (CPR). It outlines five main ethical principles - autonomy, beneficence, non-maleficence, justice, and dignity/honesty. It also discusses concepts like medical futility, advanced directives, surrogate decision makers, and guidelines for when to start or stop CPR based on patient conditions and prognosis. The document is intended to provide an overview of the ethical considerations in CPR for medical training purposes.
Rethical think.pptx for ug to study about ethics and give the bestbasawantraopatil1
This document discusses several key topics related to renal replacement therapy (RRT) for chronic kidney disease (CKD) patients, including ethical considerations. It notes that while medical professionals should promote informed consent, cultural factors may influence decision-making preferences, with some cultures preferring family involvement. Selection for dialysis should consider medical indications and prognosis. Age alone should not determine dialysis access, though it impacts survival rates and is a relevant discussion factor. Transplantation provides the best treatment but organ shortage presents ethical allocation challenges.
The document discusses advance care planning, lasting power of attorney, and advance medical directives. It provides information on:
- What advance care planning involves and its benefits in reducing crisis decision-making.
- The process of completing a lasting power of attorney, including appointing a donee to make decisions on one's behalf if mental capacity is lost.
- What an advance medical directive is and the process of completing one to inform doctors of wishes regarding life-sustaining treatment for a terminal illness.
- Challenges that can arise with implementation of these plans in real clinical situations.
Guidance at end of life (gael) for health care professionalspapahku123
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2. Plan of Talk
• Why we need(ed) a DNAR policy
• The HSE DNAR Policy
• Implementing the Policy
• Issues/Problems/Limitations of the Policy
• Advance Healthcare Directives Legislation
• Some comments on AHD
3. DNAR in Galway 2004
• Seventeen (3.5%) of 485 patients (= 35.4% of the 48 patients
close to death) were identified as not for resuscitation.
• Written confirmation of the DNR order in the nursing notes for
14 (82%) and in the medical notes for 15 (88%) patients;
• In two cases, it was reported that doctors were reluctant to write
down the agreed decision.
• Discussion with patient (2), family (10) or both (1) was recorded
in 14 cases.
(McNamee & O’Keeffe IJMS 2004)
4. CPR in Irish Long-Stay Units 2009
• 16% of residents die each year
• CPR ever in 40%, advanced CPR in 10%
• Policy in 55%, written in 13%
• Include
– All residents for CPR
– None for CPR unless pt/ family request
– Nobody over 80 years for CPR
– CPR only for staff and visitors
O’Brien & O’Keeffe (Ir J Med Sci 2009)
5.
6.
7. O’Keeffe et al Eur J Med 1993; Cotter et al Age Ageing 2008
9. General Principles
• DNAR applies only to CPR
– However, while a decision may be made to attempt CPR in
the event of cardiorespiratory arrest it may not be clinically
appropriate to provide certain other intensive treatments
and procedures. For example, prolonged support for multi-
organ failure (e.g. artificial ventilation and renal dialysis) in
an intensive care unit (ICU) may be clinically inappropriate
if the individual is unlikely to survive this, even though
his/her heart has been re-started.
• Presumption in favour of providing CPR
• Need for individual decision making – balance the benefits
and risks
• Involving the individual in discussions regarding CPR
• Respecting an individual’s refusal of CPR
10. Presumption in Favour of Providing CPR
• [T]here will be some individuals for whom no formal DNAR
decision has been made, but where attempting CPR is clearly
inappropriate because death is imminent and unavoidable, for
example, in the final stages of a terminal illness. In these
circumstances, it is reasonable for healthcare professionals
not to commence CPR.
• Some healthcare facilities may not provide all aspects of CPR
such as defibrillation. In the event of a cardiorespiratory arrest
occurring in such a facility, basic CPR and a call to the
emergency services should occur in the absence of a prior
decision not to perform CPR. The extent of the CPR
interventions available in such facilities should be notified to
prospective residents or users of the facility….
Section 5
11. Need to Consider CPR and DNAR ?
• Cardiorespiratory arrest is considered unlikely:
– ‘..general presumption in favour of CPR… However, if an
individual indicates that he/she wishes to discuss CPR, then
this should be respected. Also, the wishes of individuals with
an advance care plan refusing CPR under specific
circumstances should be respected if the directive is
considered valid and applicable to the situation that has
arisen’.
• Cardiorespiratory arrest is considered possible or likely:
– ‘Advance care planning, including CPR/DNAR is often
appropriate …and should occur in the context of a general
discussion about the individual’s prognosis and the likelihood
that CPR would be successful, as well as his/her values,
concerns, expectations and goals of care’.
Section 4
12. • Cardiorespiratory arrest, as a terminal event, is considered
inevitable
– [If] ‘death is considered to be imminent and
unavoidable…cardiorespiratory arrest may represent the
terminal event in their illness and the provision of CPR
would not be clinically indicated…. In many cases, a
sensitive but open discussion of end-of-life care will be
possible in which individuals should be helped to
understand the severity of their condition. However, it
should be emphasised that this does not necessarily
require explicit discussion of CPR or an ‘offer’ of CPR.
Implementing a DNAR order for those close to death does
not equate to “doing nothing”……’
13. Which HCP?
• It is important that the HCP ……has the requisite experience,
knowledge and communication skills.
• In general, duty rests with the most senior HCP, which would
be a consultant or registrar in the hospital setting or the
individual’s GP in other healthcare settings.
• …where a decision regarding CPR has to be made quickly
…decision-making responsibility can be delegated to less
senior healthcare professionals.
• [T]here will be some individuals for whom no formal DNAR
decision has been made, but where attempting CPR is clearly
inappropriate because death is imminent and unavoidable, for
example, in the final stages of a terminal illness. In these
circumstances, it is reasonable for healthcare professionals
not to commence CPR.
14.
15. Role of Family or Friends in Discussions
• If the individual wishes to have the support or involvement of
others, such as family or friends, in decision making, this should
be respected. If the individual is unable to participate in
discussions due to illness or incapacity, those with a close, on-
going, personal relationship with the individual may have insight
into his/her preferences, wishes and beliefs. However, their role is
not to make the final decision regarding CPR, but rather to help
the healthcare professional to make the most appropriate decision.
• Where CPR is judged inappropriate, it is good practice to inform
those close to the patient, but there is no need to seek their
‘permission’ not to perform CPR in these circumstance.
Section 3.3
16. When the Risks Outweigh
the Benefits (6.3)
• In these situations, it is appropriate for the
healthcare professional to explain the reasons
behind this judgement, including any uncertainty,
to recommend that a DNAR order should be
written, and to seek the views of the individual in
this regard.
17. When there is Disagreement about
Balance of Benefits and Risks (6.4)
• Many disagreements result from miscommunication and
misunderstandings, such as unrealistic expectation… of the likely
success of CPR or underestimation ….of the acceptability of the
current or predicted future quality of life of the individual.
• In many cases, continued discussion will lead to agreement, and an
ultimate decision should be deferred pending further discussion.
• If disagreement persists, an offer of a second, independent opinion
should be made.
• Where all efforts at resolution have proven unsuccessful it may be
necessary for parties to consider obtaining legal advice. The same
procedure should be carried out if those close to an individual who
lacks decision-making capacity do not accept a DNAR decision.
18. DNAR and Readily Reversible
Cardiorespiratory Arrests
• In certain situations, an individual with a DNAR order may suffer
a cardiorespiratory arrest from a readily reversible cause (e.g.
choking) unconnected to his/her underlying illness. In such cases
CPR would be appropriate, while the reversible cause of arrest is
treated.
• Where an individual with a DNAR order in place is to undergo a
medical or surgical procedure, it may be appropriate to review
the DNAR order...
• The process of reviewing the DNAR order should involve
discussion with the individual as part of the consent process in
advance of the procedure.
19. Reviewing DNAR orders
• The need to review a DNAR order will depend on the
rationale for the decision and should be considered within
the context of an individual’s condition and overall care.
• It may be appropriate to review decisions relating to CPR
when:
– the individual’s clinical condition changes
– the individual’s preferences regarding CPR change
– an individual who previously lacked decision-making
capacity regains his/her capacity
– clinical responsibility for the individual changes (e.g.
where he/she is being transferred or discharged).
• Any review and any subsequent decision made should be
documented accordingly.
20. Documenting and Communicating
CPR/DNAR decisions
• A decision whether or not to attempt CPR should be
clearly and accurately documented in the individual’s
healthcare record, along with how the decision was made,
the date of the decision, the rationale for it, and who was
involved in discussing the decision.
• It is recommended that service providers should develop
specific mechanisms for the documentation and
dissemination of decisions relating to resuscitation.
22. Timeline
• National Consent Policy, including
policy on DNAR, April 2013
• Draft proposals on implementing
DNAR policy, April 2014
– Not approved yet
– Will need revision
• Assisted Decision-Making
(Capacity) Act including advance
directives and designated healthcare
representatives
– Not in force yet
23. ADM Legislation
• Passed by Oireachtas Dec 18, 2015
• Signed by President Dec 30, 2015
This Act shall come into operation on such day or days as
the Minister may appoint …and different days may be so
appointed for different purposes and different provisions.
• Most provisions – Minister for Justice
• Advance directives or designated healthcare
representative – Minister for Health
24. Decision‐making vs
Documentation?
• The most important aspect of DNAR decisions is the quality and
appropriateness of any decision and of the associated discussions
and clinical judgements.
• Documenting decisions carefully will ensure that they are
understood and implemented particularly if staff who are not
familiar with the patient are on duty when a crisis does arise.
• This is very important but documentation is secondary to and
serves to effect the decision, not the other way around.
– Adequate documentation of a DNAR decision does not necessarily mean
that the decision or the decision-making process was correct
– Unsatisfactory or missing documentation does not necessarily invalidate a
DNAR decision if staff are aware that the decision has been made
following an appropriate decision-making process.
25. Documentation of DNAR
• DNAR decisions should be clearly and accurately
documented, dated and signed by a health care
professional in the individual’s healthcare record.
• Information should be provided about:
– The rationale for the decision, including whether or
not there is an advance care directive or plan
– Who was involved in discussions about the decision,
including any discussion with the person themselves
– Whether a DNAR decision is to continue indefinitely
or will be subject to review for example within a
particular time or in the event of clinical change,
26. What Mechanisms?
• Need systems to ensure that the fact that a DNAR decision has
been made is readily available to staff (who may not always be
familiar with the individual patient) to ensure that it is complied
with in the event of an emergency.
• Consider a form to be placed in a prominent position towards the
front of the notes, noting, at a minimum:
– that a DNAR decision has been made (or an advance care plan
or directive is in place),
– whether review is intended or not and
– referring those who require more information, to the date(s)
(and perhaps chart volume) of the relevant medical notes or to
the location of the advance care directive or plan.
27. • Need systems in place to ensure that DNAR decisions do
not become ‘lost’, for example, if an in-patient stay is
prolonged, if a new medical chart volume is opened or due
to staff changes and turnover.
• Approaches that may be helpful include:
– Routine communication of DNAR decisions at
handover or on transfer of care.
– Mechanisms to ensure that the ‘front form’ alerting
staff to the existence of a DNAR decision and a copy of
the primary documentation of DNAR decisions are
photocopied to new medical chart volumes
28. • Need systems in place to ensure that valid DNAR decisions
made in one setting are effectively communicated if the
patient moves to another setting.
• If an indefinite DNAR order is made, it is important that this
is communicated effectively across settings. This requires
that those in settings other than that in which the original
decision was originally made can be confident that it was a
valid decision, that is one made, after appropriate
consultation, by somebody with the requisite expertise or in
the case of an advance directive or plan that it was made in a
valid fashion by the person themselves. This would
…require, at a minimum, information on who had made the
decision, why and whether it was intended to have indefinite
effect.
29. One Size Fits All?
• Think Ahead
• Let Me Decide
• POLST
• UFTO
31. Issues with the policy
• Applies to all HSE settings (community, long-stay,
hospice, acute hospital)
• Cannot cover all situations that may arise
• Needs revision when advance directives law in force
• Lack of Irish case law
• Implications of Tracey judgement in UK
32. • Near-drowning – spastic quadriplegic, blind,
incontinent
• Ward of Court
• Parents opposed to DNAR – seeking stem cell
• Decision for Court – best interests grounds
33. • Severe spastic quadriplegia, epilepsy, congenital
heart condition, recurrent life-threatening infections
• Parents support DNAR
• Justice O’Malley
There is a strong presumption in favour of life-saving
treatment ….However, in exceptional circumstances,
authorisation may be given that steps not be taken to prolong
life.
34. Tracey Case UK Court of Appeal
• 63yo - metastatic lung cancer estimated prognosis 9 months - admitted after
RTA with serious cervical fracture.
• Intubated and ventilated, two failed extubations. Family informed that, if the
third extubation failed, she would be ‘allowed to slip away’
• No documentation of a discussion with JT.
• DNACPR form was written, JT successfully extubated and moved to the ward.
• Family discovered the DNACPR, asked that it be removed, which was done.
• JT deteriorated and, after discussions with family (JT clear at this point she did
not want to discuss herself), a second DNACPR form was completed
• JT died without attempted CPR.
Case alleging Trust in breach of JT’s human rights by
1. Not informing her of a DNACPR form that had been written while she was
in intensive care, and
2. Not having an adequately accessible DNACPR policy,
35. Tracey Judgement UK
• A DNACPR decision potentially deprives a patient of ‘life-sustaining
treatment’.
• There should be a presumption in favour of involving the patient; not to do
so deprives the patient of the opportunity to seek a second opinion.
• Not to discuss or explain a decision about CPR with the patient would be in
potential breach of Article 8 of the Euro Convention on Human Rights (the
right to private and family life), which requires that individuals be notified
and consulted with respect to decisions about their care.
• If a clinician ‘considers that CPR will not work’ the patient cannot demand
it, but this does not mean that the patient is not entitled to know that the
clinical decision has been taken.
• Only if discussions about CPR are likely to cause ‘physical or
psychological harm to the patient’ may they be omitted; finding the topic
‘distressing’ should not be a reason to omit them.
• The court rejected the submission that there was a legal requirement for a
national resuscitation policy.
Clinical Medicine 2014 Vol 14, No 6: 571–6
36. How it can go wrong?
• Spirit vs letter of policy
• Obsession with forms and documentation
– Automatic reviews
– ‘Do they have capacity?’
• Power struggles
– ‘I’m the decider!’
– Who’s the ‘next of kin’
38. Advance Directives
“Where a competent adult makes a specific and
informed decision to refuse future medical
treatment in the event of his/her incapacity, this
should be respected”.
Medical Council
“Irish Common Law may recognise an advance
care directive …. but in the Commission’s view,
the lack of clear guidance to date illustrates the
need for legislation”.
Law Reform Commission
39.
40. Definition
• An advance expression of will and preferences made by
an adult with capacity …..concerning treatment
decisions that may arise in the event that the person
subsequently loses capacity
• Can refuse treatment (including for reasons of religious
beliefs) even if that refusal
– Appears to be an unwise decision
– Seems not to be based on sound medical principles or
– May result in death
41. What Treatment?
• Treatment included interventions done for a
therapeutic, preventative, diagnostic, palliative or
other purpose related to the physical or mental
health of the person, and includes life-sustaining
treatment such as artificial nutrition and hydration.
• Basic care – including (but is not limited to)
warmth, shelter, oral nutrition, oral hydration and
hygiene measures - is not treatment and AHD does
not apply.
42. What Format?
• In writing and contain:
– Name, date of birth and contact details of the
directive-maker;
– Dated signature of the maker
– Details and signature of designated healthcare
representative (if any);
– Signatures of 2 witnesses of whom at least one
is not an immediate family member of the
directive-maker.
43. Treatment Refusal
• Legally binding, must be complied with if 3 conditions met
– At the time in question the maker of AHD lacks capacity to give consent
to the treatment
– The treatment to be refused is clearly identified
– The circumstances in which the refusal of treatment is intended to apply
are clearly identified in the AHD
• A refusal of life-sustaining treatment must be substantiated by a
statement in the AHD that the AHD is to apply to that treatment
even if his or her life is at risk
• Failure to comply with a valid AHD gives rise to civil and
criminal liability unless a healthcare professional
– Had reasonable grounds to believe that refusal was not valid or applicable
or both
– Was unaware of the existence and contents of an AHD at the time the
specified treated was carried out or continued
44. Request for Treatment
• A request for treatment in AHD is not legally binding but
shall be taken into account during any decision-making
process
• Where request for specific treatment in AHD is not
complied with, the healthcare professional shall
– Record reason for not complying with AHD in health record
– Give a copy of reasons to person’s designated healthcare
representative as soon as practicable but in any case, not later
than 7 working days after they have been recorded
45. Validity and Applicability of AHD
• Not valid
– If not made voluntarily
– While the person had capacity, has done anything clearly inconsistent
with the AHD
• Not applicable
– Person still has capacity to consent to or refuse treatment
– Treatment in question is not broadly recognisable as specific treatment
set out in AHD
– The circumstances set out in AHD as to when such specific treatment is
to be requested or refused, are materially absent or different
– Relates to basic care
• An AHD made outside the State but which substantially complies with the
requirements of Irish requirements shall have the same force and effect in
the State as if it were made in the State.
46. Designated Healthcare Representative
• Person can designate a named individual (or alternate) to
exercise the powers of a designated healthcare representative
• The directive-maker may confer on the designated healthcare
representative the powers:
– To advise and interpret what the directive-maker’s will and
preferences are regarding treatments
– To consent to or refuse treatment, up to and including refusal
of life-sustaining treatment based on the known will and
preferences of the directive-maker
• Designated Healthcare Representative shall:
– Make and keep a record in writing of decisions made
– Produce record for inspection at request of Director of
Decision Support Service
47. Register of AHDs
• Regulations will require
– Maker of AHD to give notice of the making of an
AHD to the Director of Decision Support Service
and to other specified persons
• Regulation will require
– Director of Decision Support Service to establish
a Register of AHD notified to him or her
49. Will People Complete ADs
• USA – 18% of general population
• Study of 17,000 deaths (Hanson, Arch Intern Med 1996)
– 9.8% living will
– More in white, educated, wealthy
– More in chronically or terminally ill
• 50% of Jehovah’s Witnesses had failed to
maintain up-to-date Medical Directive cards
(Watchtower)
50. Advance Planning
Advance care planning is a process of discussion
and reflection about goals, values and
preferences for future treatment in the context
of an anticipated deterioration in the patient's
condition with loss of capacity to make decisions
and communicate these to others
Long Term Conditions Collaborative: Improving Complex Care.
Scottish Government
51. Value of Advance Directives?
• Depends how far advanced?
• Discussions about end of life care
– Involves education, discussion, debate
– Often repeated
– Rarely rigid directive
52.
53. Conclusions
• A long way from ‘solving’ issue of DNAR
• Policy implementation and (perhaps) revision
needed.
• AHD legislation pending