CH28. Basic Life Support, Resuscitation and DNACPR
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Basic Life Support, Resuscitation and DNACPR Policy
Policy Statement
This policy applies to all situations in which basic life support, including resuscitation, may be indicated or needed in the context of care service delivery. It describes the responsibilities of staff present at the time and the limits to those responsibilities. Its purpose is to identify the policy and procedures on the resuscitation of people using services requiring emergency care following sudden collapse or illness. It can be referred to by all care providers.
The policy needs to be implemented in the contexts of the care of terminally ill people, their palliative care and symptom and pain control, and in cases where a person using services suddenly collapses, and similar medical emergencies.
It is based on the principle that everyone has the right to make choices and decisions about their treatment in the event of their needing to be resuscitated and these wishes should be respected if the situation arises. As far as possible, people’s wishes should be ascertained and recorded on their care and support plan; taking into account that this process will require sensitive and careful handling.
The person’s capacity to take decisions for themselves will need to be taken into account, but once taken it needs to be respected as will any associated wish such as keeping the decision confidential from relatives and others. {{org_field_name}} may need to clarify its ethical and legal position in cases, for example, where there are doubts about a person’s capacity.
The Covid-19 pandemic raised specific challenges for people using care home services, their families and staff. People living in care homes were particularly vulnerable to the infection and outbreaks.
People using services were encouraged to lodge any Advance Treatment Directive, DNACPR, or Living Will with their medical practitioner, and where applicable, their care provider (see below) if they did not wish to be resuscitated in a life-threatening or emergency situation involving cardiac arrest.
At the height of the Covid-19 pandemic, people having an advanced care plan (ACP) in place or being able to review existing ACPs was of high importance and remains so as we move forward post pandemic.
All people living in care homes have now been offered Covid-19 vaccinations and this has had a positive impact protecting this vulnerable group, and a huge reduction of mortality caused by Covid-19. There remain some people who have chosen not to be vaccinated, so potentially remain at risk of more severe forms of the virus, which is still in circulation.
Consequently, advance care plans may have resulted in the discussion and completion of “do not attempt cardiopulmonary resuscitation” (DNACPR) or Resuscitation Council UK Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms.
This policy also reflects CQC report findings from Protect, Respect, Connect — Decisions About Living and Dying Well During COVID-19 (2021) and understands applying a DNACPR decision to groups of people of any description, referred to as “blanket” DNACPR is potentially discriminatory and unlawful under the Equality Act 2010.
{{org_field_name}} is mindful of the Universal Principles for Advance Care Planning (2022) implementing recommendations of the CQC report into the use of DNACPR decisions taken during the Covid-19 pandemic, and follow the values of: inclusion, equality, and diversity country wide. LINK Universal principles for advance care planning
Comprehensive documentation is maintained relating to DNACPR decisions, including sharing of information and records of compassionate conversations and decisions agreed with patients, families and representatives to enable them to move around the system well.
When implementing a DNACPR, this is done following individual assessment of each situation, in consultation with the individual and their family. When a DNACPR decision is made individuals are informed when it will be reviewed, which will be each time individual’s situation changes and such information recorded.
Reasonable adjustments are made for disabled people to remove any information or communication barriers. Clear information about DNACPR decisions is made available, in accessible formats and languages.
All staff will receive guidance and learning opportunities to clarify their attitudes and feelings over such issues and to understand their respective roles and responsibilities in such situations.
Basic Life Support Procedures
In incidents of sudden or unexpected collapse where a person has clearly not made any living will or given any indication of their views on resuscitation, best efforts to provide basic life support and, if needed, resuscitation, will be carried out in line with the competence and qualifications of available staff to offer emergency treatment or first aid.
The Resuscitation Council guidance on resuscitation of those with Covid-19 was updated in 2022. New evidence suggests a low likelihood of airway management manoeuvres being aerosol generating, leading to the removal of airway management manoeuvres from the list of aerosol generating procedures (AGP).
Further evidence is awaited on whether chest compressions generate aerosol and until such evidence emerges, the Resuscitation Council remains concerned regarding the provision of chest compressions and the proximity of the rescuer to the person, which may constitute a risk of aerosol transmission.
Covid-19 Supplement to the Infection Prevention and Control Resource for Adult Social Care should be followed.
Medical and nursing care for those who are at the end of life must follow local/national policy.
In these situations, the service will follow as far as practically possible Resuscitation Council (2015) guidelines, which state as follows.
- “Ensure it is safe to approach the victim.
- Promptly assess the unresponsive victim to determine if they are breathing normally.
- Be suspicious of cardiac arrest in any patient presenting with seizures and carefully assess whether the victim is breathing normally.
- For the victim who is unresponsive and not breathing normally:
a. Dial 999 and ask for an ambulance. If possible, stay with the victim and get someone else to make the emergency call.
b. Start Cardiac Pulmonary Resuscitation (CPR) and send for an automated external defibrillator (AED) as soon as possible.
c. If trained and able, combine chest compressions and rescue breaths, otherwise provide compression-only CPR.
d. If an AED arrives, switch it on and follow the instructions.
e. Minimise interruptions to CPR when attaching the AED pads to the victim. - Do not stop CPR unless you are certain the victim has recovered and is breathing normally or a health professional tells you to stop.
- Treat the victim who is choking by encouraging them to cough. If the victim deteriorates give up to five back slaps followed by up to five abdominal thrusts. If the victim becomes unconscious — start CPR. In most cases, it will be imperative to summon medical help and the emergency services without delay”.
Only staff who are available and who are competent and qualified to provide resuscitation, including the use of appropriate equipment and appliances, will be expected to do so but all staff will be expected to provide normal standards of help and comfort, eg pending the arrival of the emergency services or medical help, including where it is known that the person has a DNACPR.
Further interventions will then be directed by the medical practitioner and/or paramedical practitioners. If the staff are aware that the ill person has made a living will or clear statement that they do not wish to be resuscitated then this should be passed on to the medical team.
Advance directives
The service will always check if the victim has made an advance directive or DNACPR. An advance directive states the sort of treatment a person would want for different levels of illness, such as a critical or terminal illness, permanent unconsciousness or dementia.
An advance directive will tell medical doctors and healthcare professionals that the person does not want certain types of treatment, such as to be put on a ventilator if in a coma. But it can also say that the person would like a certain treatment or to receive whatever treatment is available that might keep the person alive.
A living will is one type of an advance directive, which only comes into effect when a person is terminally ill (which generally is held to mean less than six months to live), for example, with widespread cancer. A living will does not let the person choose another person to make decisions for them unless it specifically appoints a proxy.
Training
The manager is responsible for ensuring that all members of staff understand the resuscitation policy and their roles should a person using services suffer a cardiopulmonary arrest. Staff will also receive training in basic life support procedures to respond competently and correctly in medical emergencies as described in this policy.
Staff involved in DNACPR decisions will have the knowledge, skills and tools to deliver personalised approaches in accordance with relevant legislation and are aware of mechanisms to raise concerns.
References
- Statement: Updates to RCUK Covid-19 Guidance in April 2022 (2022), available on the Resuscitation Council UK website
- Royal College of Nursing Guidance on DNACPR and Verification of Death (2020), available on the RCN website
- Protect, Respect, Connect — Decisions About Living and Dying Well During Covid-19 (2021), available on the CQC website
- Covid-19 Supplement to the Infection Prevention and Control Resource for Adult Social Care (updated 2023), available on the GOV.UK website.
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