References

Almack K, Cox K, Moghaddam N, Pollock K, Seymour J. After you: conversations between patients and healthcare professionals in planning for end of life care. BMC Palliat Care. 2012; 11 https://doi.org/10.1186/1472-684X-11-15

Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000; 5:(1)302-311 https://doi.org/10.1634/theoncologist.5-4-302

Berry PA. The implications of mandatory do not attempt cardiopulmonary resuscitation discussions. Int J Palliat Nurs. 2014; 20:(7)323-325 https://doi.org/10.12968/ijpn.2014.20.7.323

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3:(2)77-101

Brannstrom M, Jaarsma T. Struggling with issues about cardiopulmonary resuscitation (CPR) for end-stage heart failure patients. Scand J Caring Sci. 2015; 29:(2)379-385 https://doi.org/10.1111/scs.12174

British Medical Association, Resuscitation Council UK, Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation: guidance from the BMA, Resuscitation Council UK and RCN. 2016. https://tinyurl.com/p5oczdw (accessed 7 January 2020)

Chang H. Autoethnography in health research: growing pains?. Qual Health Res. 2016; 26:(4)443-451 https://doi.org/10.1177/1049732315627432

Choice in End of Life Care Programme Board. What's important to me: a review of choice in end of life care. 2015. https://tinyurl.com/y5juhxtd (accessed 7 January 2020)

Cohen S, Fritz Z, Frankau J, Laroche C, Fuld J. Do Not Attempt Cardiopulmonary Resuscitation orders in acute medical settings: a qualitative study. QJM. 2013; 106:(2)165-177 https://doi.org/10.1093/qjmed/hcs222

Cox K, Wilson E, Jones L, Fyfe D. An exploratory, interview study of oncology patients' and healthcare staff experiences of discussing resuscitation. Psychooncology. 2007; 16:(11)985-993 https://doi.org/10.1002/pon.1155

Creswell JW. Research design: qualitative, quantitative and mixed methods approaches, 4th edn. London: Sage; 2014

Darawsheh W, Stanley M. Reflexivity in research: Promoting rigour, reliability and validity in qualitative research. Int J Therapy Rehab. 2014; 21:(12)560-568 https://doi.org/10.12968/ijtr.2014.21.12.560

Department of Health and Social Care. More care, less pathway: a review of the Liverpool care pathway. 2013. https://tinyurl.com/y3hq3wsc (accessed 7 January 2020)

Dixon J, King D, Knapp M. Advance care planning in England: is there an association with place of death? Secondary analysis of data from the National Survey of Bereaved People. BMJ Support Palliat Care. 2019; 9:(3)316-325 https://doi.org/10.1136/bmjspcare-2015-000971

Garner K, Goodwin J, McSweeney J, Kirchner J. Nurse executives' perceptions of end of life are provided in hospitals. J Pain Symptom Manage. 2013; 45:(2)235-243 https://doi.org/10.1016/j.jpainsymman.2012.02.021

General Medical Council. Treatment and care towards the end of life: good practice in decision making. 2010. https://tinyurl.com/yj6ftkf5 (accessed 7 January 2020)

Granek L, Monika K, Krzyzanowska MK, Tozer R, Mazzotta P. Oncologists strategies and barriers to effective communication about the end of life. J Oncol Pract. 2013; 9:(4)e129-135 https://doi.org/10.1200/JOP.2012.000800

Hall C, Lugton J, Spiller J, Carduff E. CPR decision-making conversations in the UK: an integrative review. BMJ Support Palliat Care. 2019; 9:1-11 https://doi.org/10.1136/bmjspcare-2018-001526

Hanratty B, Lowson E, Holmes L Breaking bad news sensitively: what is important in their last year of life?. BMJ Support Palliat Care. 2012; 2:(1)24-28 https://doi.org/10.1136/bmjspcare-2011-000084

Healthcare Quality Improvement Partnership. National audit of care at the end of life: first round of the audit (2018/19) report, England and Wales. 2019. https://tinyurl.com/ygt4knf2 (accessed 7 January 2020)

Heyland DK, Frank C, Groll D Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalised patients and family members. Chest. 2006; 130:(2)419-428 https://doi.org/10.1378/chest.130.2.419

Holland CL, Bowker LK, Myint PK. Barriers to involving older people in their resuscitation decisions: the primary-secondary care mismatch highlights the potential role of general practitioners. Int J Clin Pract. 2013; 67:(4)379-384 https://doi.org/10.1111/ijcp.12067

House of Commons Health Committee. End of life care: fifth report of session 2014–2015. 2015. https://tinyurl.com/yal85qne (accessed 7 January 2020)

Kazmierski M, King N. Role of the community matron in advance care planning and ‘do not attempt CPR’ decision-making: a qualitative study. Br J Community Nurs. 2015; 20:(1)19-24 https://doi.org/10.12968/bjcn.2015.20.1.19

Leadership Alliance for the Care of Dying People. One chance to get it right: improving people's experience of care in the last few hours and days of life. 2014. https://tinyurl.com/yymoxsag (accessed 7 January 2020)

Low C, Finucane A, Mason B, Spiller J. Palliative care staff 's perceptions of do not attempt cardiopulmonary resuscitation discussions. Int J Palliat Nurs. 2014; 20:(7)327-333 https://doi.org/10.12968/ijpn.2014.20.7.327

Macmillan Cancer Support. Missed opportunities: advance care planning report. 2018. https://tinyurl.com/y74gqapb (accessed 7 January 2020)

Miller S, Dorman S. Resuscitation decisions for patients dying in the community: a qualitative interview study of general practitioner perspectives. Palliat Med. 2014; 28:(8)1053-1061 https://doi.org/10.1177/0269216314531521

National Palliative and End of Life care Partnership. Ambitions for palliative and end of life care: a national framework for local action 2015–2020. 2015. http://www.endoflifecareambitions.org.uk (accessed 7 January 2020)

Resuscitation guidelines. 2015. https://tinyurl.com/ycq4fjcf (accessed 7 January 2020)

Parliamentary and Health Service Ombudsman. Dying without dignity. Investigation by the Parliamentary and Health Service Ombudsman into complaints about end of life care. 2015. https://tinyurl.com/ybmbct55 (accessed 7 January 2020)

Petterson M, Hedstrom M, Hoglund A. Striving for good nursing care: nurses' experiences of do not resuscitate orders within oncology and haematology care. Nurs Ethics. 2014; 21:(8)902-915 https://doi.org/10.1177/0969733014533238

Pollock K, Wilson E. Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life. Health Serv Delivery Res. 2015; 3:(31) https://doi.org/10.3310/hsdr03310

Royal College of Physicians. Talking about dying: how to begin honest conversations about what lies ahead. 2018. https://tinyurl.com/yaapt89w (accessed 7 January 2020)

Royal College of Physicians and Marie Curie Cancer Care. National care of the dying audit for hospitals, England. National report. 2014. https://tinyurl.om/yk2eaf5b (accessed 7 January 2020)

Saevareid TJ, Balandin S. Nurses' perceptions of attempting cardiopulmonary resuscitation on oldest old patients. J Adv Nurs. 2011; 67:(8)1739-1748 https://doi.org/10.1111/j.1365-2648.2011.05622.x

Smith J, Firth J. Qualitative data analysis: the framework approach. Nurse Res. 2011; 18:(2)52-62 https://doi.org/10.7748/nr2011.01.18.2.52.c8284

Do not attempt cardiopulmonary resuscitation: top tips on how to start conversations for healthcare providers [video]. 2016. https://tinyurl.com/ye5mck9r (accessed 7 January 2020)

Managing Do Not Attempt Cardiopulmonary Resuscitation conversations in the community

02 February 2020
Volume 25 · Issue 2

Abstract

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).

Register now to continue reading

Thank you for visiting Community Nursing and reading some of our peer-reviewed resources for district and community nurses. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to clinical or professional articles

  • New content and clinical newsletter updates each month