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Managing Do Not Attempt Cardiopulmonary Resuscitation conversations in the community

02 February 2020
Volume 25 · Issue 2


Clear, sensitive and timely communication with palliative and end-of-life (EoL) patients and their families is important. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) conversations can help patients accept their impending death and achieve a more dignified death. This research explored the experiences and communication strategies of clinical nurse specialists (CNSs) in palliative care when managing DNACPR conversations in the community. Six semi-structured interviews were conducted with community palliative care CNSs, and the results were summarised using autoethnography. Delays in EoL discussions mean that some community palliative care CNSs are having DNACPR conversations at their first meeting with patients. Balancing being clear and sensitive is challenging, especially when patients and families have previously been informed inappropriately or insensitively about DNACPR decisions. DNACPR discussions should be initiated by exploring patient understanding and preferences while emphasising care continuation and a more dignified death.

Despite a national drive to support quality in end-of-life (EoL) care, many dying patients are not identified in a timely manner, with communication and care at this stage often being poor (Healthcare Quality Improvement Partnership, 2019), which may necessitate unnecessary interventions and cause distress (Parliamentary and Health Service Ombudsman, 2015). Do not attempt cardiopulmonary resuscitation (DNACPR) decisions can help promote a dignified death for patients who are thought to be dying (General Medical Council (GMC), 2010). The success rate of cardiopulmonary resuscitation (CPR) on patients with deteriorating progressive illnesses is poor, at typically less than 19% (Nolan et al, 2015), and even less, at 5–10% outside of the acute setting (British Medical Association (BMA) et al, 2016).

While the benefits of advance care planning (ACP) are widely recognised (Dixon et al, 2019), many patients are not given the opportunity to express their EoL choices in advance (The Choice in End of Life Care Programme Board, 2015; Healthcare Quality Improvement Partnership, 2019). The Healthcare Quality Improvement Partnership (2019) identified that, although a DNACPR was in place for 97% of patients who died, a DNACPR discussion with the patient was recorded in only 42% of cases. While some patients are reported to postpone ACP discussions until they are closer to death (Pollock and Wilson, 2015), many individuals want to discuss their future care preferences (The Choice in End of Life Care Programme Board, 2015; Macmillan Cancer Support, 2018) at a time when they feel well enough to process the information but also not too close to being given their initial diagnosis (Cox et al, 2007). DNACPR discussions are often delayed, taking place, on average, at 31 hours prior to death (Royal College of Physicians and Marie Curie Cancer Care, 2014).

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