Liverpool Care Pathway - A Land Of Confusion

When policy is made without clarity of thought and without reference, then will confusion reign.



Is everyone dying to plan?

This is alarming. This is really quite horrifying.

These are extracts from NHS Kirklees Do Not Attempt Cardiopulmonary Resuscitation Policy (DNA CPR) –

It is a stated intention

• to make DNA CPR decisions transparent and open to examination

But

6.2 There is no ethical obligation to discuss resuscitation measures with patients for whom such a treatment, following assessment is judged to be futile, unless the patient raises the issue.

Appendix 2 of the Document discusses grooming techniques to use should a discussion on DNA CPR raise its ugly head.

All NHS Kirklees employees are required to follow this policy under threat of disciplinary action being taken against them for non-compliance.

And yet...

This is a statement by Resuscitation Council (UK) -

The guidance stresses that although the responsibility for decision-making rests with the most senior clinician, these decisions should not be made in isolation, but where appropriate, should involve the patient (or those close to the patient if s/he lacks capacity) and others involved in the clinical care of the patient. Teamwork and good communication are of paramount importance.

The statement looks into misleading reports on nurse leads making decisions on DNA CPR...

Following misleading press coverage, some confusion has arisen about two statements in the document relating to the role of senior nurses in making decisions about cardiopulmonary resuscitation (CPR). The statements appear in sections 6 and 13 of the document. Erroneous reporting led to some concerns that doctors' opinions could be superseded, patients insufficiently consulted or that inexperienced nurses might make such decisions. Consideration of the statements in the context of the entire document makes clear these are misinterpretations.

This is the document -

The offending sections -

6. Clinical decisions not to attempt CPR

The responsibility for making the decision rests with the most senior clinician currently in charge of the patient’s care, although they may delegate the task to another person who is competent to carry it out. Wherever possible, a decision should be agreed with the whole healthcare team. The overall clinical responsibility for decisions about CPR, including DNAR decisions, rests with the most senior clinician in charge of the patient’s care as defined by local policy. The most senior clinician could be a consultant, GP or suitably experienced nurse. In certain settings an experienced nurse may be the senior clinical decision maker. Examples include nurse consultants or senior clinical nurses working in palliative care.

13. Responsibility for decision-making

The overall clinical responsibility for decisions about CPR, including DNAR decisions, rests with the most senior clinician in charge of the patient’s care as defined by local policy. This could be a consultant, GP or suitably experienced nurse. He or she should always be prepared to discuss a CPR decision for any individual patient with other health professionals involved in the patient’s care.



According to this BMJ abstract, The East Midlands DNA-CPR form may be completed by a ‘suitably experienced nurse’. The BMA and RCN statement (2007) indicated that nurses may make such decisions, but ambiguity about training and governance remains. Senior community nurses, with previous advanced communication skills training, attended training using the e-ELCA Discussing ‘do not attempt CPR’ decisions. Subsequently nurses could take on the role of signing DNA-CPR forms if agreed by their employer.

- BMJ

13 of 36 questionnaires were returned. Those with patients on the LCP now completed the DNA-CPR form unless there were difficult dynamics. All completed it for any patient requesting DNA-CPR and 77% completed it with some patients for whom there was no chance of success from CPR. Where such patients or relatives were not in agreement the nurse sought involvement of a doctor. All nurses felt more confident to discuss the topic of CPR and much more confident in discussing a DNA-CPR decision for a dying patient (‘informing’ not ‘asking’), and in dealing with the reactions. Only one nurse reported more difficulties, arising with GPs who were less confident. None of the nurses had had their signature queried by a colleague or relative and many GPs were appreciative of this role. Only two nurses wanted formal assessment of their competence. Some considered assessment to add value if it enhanced the confidence of others in them. 55% wanted on-going CPD, considering this more likely than assessment to quality assure their practice.

And this report in Nursing Times headlines nurses having authority to make decisions.

- Nursing Times

Senior nurses should have the authority to make key decisions about cardiopulmonary resuscitation, according to new landmark guidance. Richard Staines investigates

LATEST guidelines from the RCN, BMA and Resuscitation Council pave the way for nurses to make clinical decisions on whether or not to attempt cardiopulmonary resuscitation.

Much of the document, published last week, provides guidance on changes in the law regarding Do Not Attempt Resuscitation decisions under the Mental Capacity Act 2005.

A key difference between this and 2001 guidance is nurses are now considered, in some cases, better placed than doctors to make such decisions – both in setting DNAR orders and in making decisions where there is no such order or circumstances mitigate against one.

Ignorance and confusion reign supreme.

'LCP' nurses abroad the net make blatant claims that they make these decisions without reference to patients.

Do those who make the law also break the law? It would appear to be open to any interpretation that is found convenient.

- The Telegraph

And this is the world we live in...