Do Not Attempt Cardio Pulmonary Policy

Document name: Do Not Attempt Cardio Pulmonary Resuscitation Policy (D.N.A.C.P.R)

Document type: Policy

Staff group to whom it All clinical staff within the Trust applies:

Distribution: The whole of the Trust

How to access: Intranet

Issue date: April 2015

Next review: April 2017

Approved by: EMT

Developed by: Specialist Resuscitation Officer/Resuscitation Trust Action Group

Director lead: Director of Nursing, Clinical Governance and Safety

Contact for advice: Simon Gillott, Specialist Resuscitation Officer Janet Owen, End Of Life Care Clinical Lead Contents

Section Page

1. Introduction 4

2. Purpose 4

3. Duties 4

4. Equality impact assessment 5

5. Process for monitoring compliance 6

6. Review and revision arrangements 6

7. Training provision 6

8. Definitions 6

9. Key principles 7

10 Circumstances of cardio-pulmonary arrest 7

10.1 Cardio pulmonary arrest is not anticipated 7

10.2 When CPR would fail 8

11 Communication 8

12 Quality of life 8

13 Presumption to resuscitate 9 10 14 Procedure 10 14.1 In-patient (Bed based) services 11 14.2 The review date

14.3 Community setting 11 14.4 When it is not possible to anticipate circumstances where cardiopulmonary 12 arrest might happen 14.5 When it is possible to anticipate circumstances where cardiopulmonary arrest 13 seems likely 14.6 CPR would realistically have a possibility of medically successful outcome 13

14.7 Patients with a DNACPR decision being transferred by ambulance 14

15. References 15 APPENDICIES Page

Appendix 1 Yorkshire and Humber DNACPR form 16

Appendix 2 Equality Impact Assessment 18

Appendix 3 20 Checklist for the review and approval of procedural documents Appendix 4 Version control sheet 22 DO NOT ATTEMPT CARDIO PULMONARY RESUSCITATION POLICY

1. Introduction

The aim of the Do Not Attempt Cardio Pulmonary Resuscitation Policy (DNACPR) is to seek to ensure appropriate, lawful and consistent decision making about the resuscitation of patients. The policy provides a framework setting out the basic principles upon which decisions are made not to attempt cardiopulmonary resuscitation (CPR) in identified patients. This policy will also provide the framework for people with mental capacity to decline CPR treatment. The policy is based on guidelines produced by the British Medical Association, Royal College of Nursing and Resuscitation Council (UK) (2014and has been developed alongside the development of Yorkshire &Humber Regional DNACPR form. The policy has been written to support NHSLA Risk Management Standards concerning the deteriorating patient 2012/2013 and must be read in conjunction with the Trusts Cardiopulmonary Resuscitation policy.

This document is an update of an existing policy.

2. Purpose

Policies and individual decisions about CPR must comply with the Human Rights Act 1998. This Act incorporates the bulk of the rights set out in the European Convention on Human Rights into UK law. In order to meet their obligations under the Act, health professionals must be able to show that their decisions are compatible with the human rights set out in the Articles of the Convention. Provisions particularly relevant to decisions about attempting CPR include the right to life (Article 2), to be free from inhuman or degrading treatment (Article 3), to respect for privacy and family life (Article 8), to freedom of expression, which includes the right to hold opinions and to receive information (Article 10) and to be free from discriminatory practice in respect of these rights (Article 14). The Mental Capacity Act (2005) allows advanced decisions refusing CPR to be legally binding on healthcare professionals. Some with the mental capacity to do so may wish to make an Advance Decision to refuse treatment (such as CPR) that they would not wish to receive in some future circumstances. For further information see SWYPFT Mental Capacity Act (2005) Policy and guidance.

3. Duties

Trust Board The Trust Board is ultimately responsible for the delivery of optimum clinical care and recognising the significance of national guidance to enhance delivery. The Trust Board are required to assure themselves that national guidance is being adopted and appropriately processed and managed in a timely fashion.

Chief Executive The Chief Executive is responsible for ensuring that resources and mechanisms are in place for the overall implementation, monitoring and review of this policy.

Medical Director The Medical Director is responsible for supporting implementation of this policy.

Director of Nursing, Clinical Governance and Safety The Director of Nursing, Clinical Governance and Safety has overall responsibility for the implementation of this policy in accordance with the guidance issued by the Resuscitation Council and British Medical Association and will: • Ensure that mechanisms are in place to ensure that all staff who treat or come into contact with a patient with a DNACPR order in place deliver care in accordance with this policy • Ensure adherence to the various national guidelines and standards contained in the policy. • Ensure that robust monitoring and audit arrangements are in place to demonstrate compliance to and effectiveness of this policy

District Directors and Senior Managers/Service Managers Directors and senior managers/service managers are responsible for the implementation of this policy within their directorate and service areas.

Ward/unit managers/team leaders Ward/unit managers/team leaders are responsible for providing guidance to managed staff and overseeing compliance with this policy.

Trust Resuscitation TAG Monitor implementation of the policy

Consultants/Medical Staff/General Practitioners The ultimate responsibility for a DNACPR decisions rests with the Consultant/GP in charge of the patients care.

Staff It is the responsibility of all staff who treat or support access to Trust services when dealing with any patient known to have a DNACPR decision in place to be familiar with this DNACPR Policy & Procedure.

4. Equality impact assessment

The organisation aims to design and implement services, policies and measures that meet the diverse needs of the service, population and workforce, ensuring that none are placed at a disadvantage over others. The Equality Impact Assessment tool has been utilised to ensure equality has been assessed within this policy.

5. Process for monitoring compliance of this policy

The audit will be commissioned by the Resuscitation TAG. BDU directors will be responsible for ensuring implementation and monitoring of the action plan. Results and actions will be reported through the Trust’s Resuscitation Trust Action Group and Clinical Governance and Clinical Safety Committee.

6. Review and revision arrangements

The policy will be reviewed by the agreed review date, in line with the trust ‘Policy for the development, approval and dissemination of policy and procedural documents’, or earlier if required. Responsibility for initiating a review lies with the Director of Nursing, Clinical Governance and Safety. The Executive Management Team will be responsible for approving the new policy. The Integrated Governance Manager is responsible for ensuring the new version of the policy is in the electronic document store, for ensuring the document being replaced is removed from the document store and that an electronic and paper copy, clearly marked with version details, are retained as a corporate record. The Integrated Governance Manager will also be responsible for ensuring that the new version of the policy is communicated via the staff brief. 7. Training provision

Training will be commissioned by the Resuscitation TAG. 8. Definitions.

Cardio – Respiratory Arrest Cardio-Respiratory Arrest is the cessation of cardiac function and cessation of breathing. It is manifest by the absence of breathing and pulse. Failure of these functions is an inevitable part of dying and cardio-respiratory arrest represents in some patients a terminal event in their illness.

Cardio-Pulmonary Resuscitation Cardio-Pulmonary Resuscitation (CPR) is the procedure of providing external heart compression coupled with artificial respiration. CPR measures do not include analgesia, antibiotics, drugs for symptom control, feeding or hydration (by any route), investigation and treatment of a reversible condition, seizure control, suction, and treatment for choking. Comfort and treatment measures must be instituted after assessment, consultation with patient and relevant others, and on the basis of clinical need irrespective of whether a DNACPR form is present or not. The phrase “do not attempt cardiopulmonary resuscitation” should be used, rather than “do not resuscitate” or “do not attempt resuscitation” to avoid confusion. DNACPR Decision Documentary evidence of decision not to attempt resuscitation on an identified patient. This may be a DNACPR pro-forma (supporting documented evidence about the rationale for the decision and communication about this decision should be in the medical notes) or a valid advanced decision to refuse treatment.

Relevant others Term to describe patient’s relatives, carers, representatives, advocates, people with lasting power of attorney, independent mental capacity advocates and court appointed deputies

Senior clinician 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.

9. KEY PRINCIPLES

The primary goal of healthcare is to benefit patients, by restoring or maintaining their health as far as possible, thereby maximising benefit and minimising harm. If treatment fails, or ceases to benefit the patient, or if an adult patient with capacity has refused treatment, that treatment is no longer justified.

Prolonging a patient’s life usually provides a health benefit to that patient. Nevertheless, it is not appropriate to prolong life at all costs with no regard to its quality or to the potential burdens of treatment for the patient from the patient’s perspective. The decision to use any treatment should be based on the balance of burdens, risks and benefits to the individual receiving the treatment, and that principle applies as much to cardiopulmonary resuscitation (CPR) as to any other treatment.

10 Circumstances of cardio-pulmonary arrest

10.1 Cardio pulmonary arrest is not anticipated If the circumstances of a cardio-pulmonary arrest cannot be anticipated, it is not possible to make a DNACPR decision that can have any validity in guiding the clinical team. In order to make an informed decision about the likely outcome of CPR it is essential to be able to think through the likely circumstance(s) in which it might happen for the patient. However, this should never prevent discussions about resuscitation issues with the patient if they wish. 10.2 When CPR would fail Where the clinical team has good reason to believe that a person is dying as an inevitable result of advanced irreversible disease or a catastrophic event and that CPR will not restart the heart and breathing for a sustained period the CPR should not be offered or attempted. However, the person’s individual circumstances and the most up to date evidence and professional guidance must be considered carefully before such a decision is made. The ultimate responsibility for the decision rests with the most senior clinician responsible for the person’s care but discussion of the decision and agreement or consensus of the other members of the health care team is recommended wherever possible. Discussion about resuscitation issues should occur as part of helping the patient and their family understand the severity of the patient’s condition and avoid misunderstanding, unless it is clear that such a discussion would be unwelcome or it is felt it would cause physical or psychological harm, in which case the rationale for this must be clearly documented. In most cases it is helpful to support full verbal discussion with printed information. Where the patient is not in agreement they have a right to a second opinion.

11. Communication

Throughout their care, the patient (where appropriate) should be given as much information as they wish about their situation including information about cardio pulmonary resuscitation. People with capacity should be given opportunities to talk about CPR, but information and discussion should not be forced on unwilling patients. If people indicate that they do not wish to discuss CPR this should be respected and documented.

If a best interest decision about CPR is made by the health care team because the patient declined discussion about CPR or asked the health care team to make the decision for them, this must be documented in the health care record, together with the basis for the decision. The clinical team must be able to justify their decisions. Relevant others can be given such information if the patient agrees.

If a patient does not have capacity to make this decision, then the clinical team must make a formal best interest decision, compliant with the Mental Capacity Act (2005). This will take into account the knowledge of relevant others about the patient’s previous wishes..

Clinicians should ensure that those close to the patient, who have no legal authority to make decisions for the patient but understand that their role is to help inform the decision making process, rather than being the final decision makers. These considerations should always be taken from the patients perspective.

For a patient who lacks capacity and have no family, friends or other advocate who is appropriate to be consult an independent mental capacity advocate (IMCA) should be involved if there is doubt about whether or not CPR would have a realistic chance of success or if a decision about CPR is being considered on the balance of benefits and risks in accordance with the law. The IMCA does not have the power to make the decision but must be consulted as part of the determination of the person’s best interests Discussions about cardio pulmonary resuscitation are sensitive and complex and should be undertaken by experienced medical or nursing staff. The timing and nature of discussions about resuscitation are a matter of judgement for the clinical team.

.Although printed information should never be used as a substitute for clear and full verbal discussion and provision of information, printed information should be used as well, both to raise people’s awareness of the importance of decisions about CPR and to supplement or reinforce information provided in discussion..

A copy of this policy should be available to members of the public on request.

12. Quality of life This policy adopts the view that medical decisions should be based on immediate health needs, and not on a professional’s opinion on quality of life. The decision to issue a DNACPR order or to halt a resuscitation attempt will be based only on clinical findings or the known wishes of the patient. Age, gender, religion, disability, or cultural differences will not be a factor in the decision.

Where CPR may be medically successful but result in a poor quality or length of life the patient’s wishes about not wanting resuscitation to be attempted are of paramount importance.

A decision that CPR will not be attempted, on best interest’s grounds, because the burdens outweigh the benefits should be made only after careful consideration of all relevant factors, discussions with the patient or in patients who lack capacity relevant others, and these discussions should include:

 The likelihood of re-starting the person’s heart and breathing for a sustained period  The level of recovery that can be expected realistically after successful CPR  The person’s known or ascertainable wishes, including information about previously expressed views, feelings, beliefs and values of those who lack capacity  The person’s human rights, including the right to life, the right to be free from degrading treatment, which may include dignified death, and the right to respect for a private and family life  The likelihood of the person experiencing continued pain or suffering that they would find intolerable or unacceptable  The level of awareness the person has of their existence and surroundings 13 Presumption to resuscitate

When no explicit decision has been made about resuscitation before cardiopulmonary arrest, and the expressed wishes of the patient are unknown, it should be presumed that staff would attempt to resuscitate the patient. .Although this should be the general assumption, it is unlikely to be considered reasonable to attempt to resuscitate a patient who is clearly in the terminal phase of an illness. Experienced nursing or medical staff are therefore, not obliged to initiate resuscitation measures for a patient where the death is clearly expected and due to an irreversible illness such that CPR would be unsuccessful and unquestionably futile. Mental Capacity Act [2005] confirms that an advance decision to refuse CPR will be valid and therefore legally binding on the healthcare team, if:

a The patient was 18 years old or over and had capacity when the decision was made.

b The decision is in writing, signed and witnessed.

c It includes a statement that the advance decision is to apply even if the patient’s life is at risk. d The advance decision to refuse treatment has not been withdrawn.

e The patient has not, since the advance decision to refuse treatment was made, appointed a welfare attorney to make decisions about CPR on their behalf.

f The patient has not done anything clearly inconsistent with its terms.

g The circumstances that have arisen match those envisaged in the advance to refuse treatment.

If there is any question about the validity of an advance decision to refuse treatment CPR should be attempted.

Any attempt at CPR should be performed competently and in accordance with guidelines recommended by the Resuscitation Council UK.

The responsibility for making the DNACPR decision rests with the most senior clinician currently in charge of that patient’s care, The senior doctor responsible for the patient’s care has the authority to make the final decision, but wherever possible the decision should be made by the whole healthcare team.

The occasions where a clear decision is difficult, review by the whole team should be planned. If agreement and consensus is not achieved and staff or relevant others continue to have concerns they should approach their line managers. If this is not resolved a second medical opinion should be sought. If unresolved the courts can be approached for the final decision.

14. Procedure

14.1 In-patient (Bed Based) Areas The ultimate responsibility for a DNACPR decision rests with the Consultant in charge of the patients care or On Call Consultant if the form has been signed by another clinician.

The Consultant with responsibility for the care of the patient must countersign the DNARCPR form within 72 hours.

The nurse who is informed of the medical decision to identify a patient as not for CPR must inform the nursing team and other health professionals caring for the patient of the decision and document the decision in the care plan.

Any individual subject to a DNACPR should have a care plan clearly stating that a DNACPR is in place and highlighting any review date

14.2 The review date:

a. If the individual is an inpatient then the DNACPR status is to be reviewed at least fortnightly at the consultant ward round or MDT meeting. b. DNACPR status is to be reviewed on transfer of medical responsibility (e.g. hospital to community or vice versa) c. DNACPR status should be reviewed whenever there are significant changes in a patient’s condition. The senior nurse on duty will be responsible for ensuring that all ward staff are made aware of the DNACPR decision at shift hand over and will record the currency of the DNACPR order in the patient’s care plan. Communication should include all members of the nursing/therapy team including bank and locum staff.

A DNACPR decision should be clearly documented in the patient’s medical notes and reinforced using the DNACPR pro-forma. The DNACPR decision should be communicated to the senior nurse on duty who will ensure the DNACPR pro-forma is placed within the patient’s medical notes as the first sheet.

When the form is no longer valid, either because the patient is for CPR or because a new form has been started, it must be marked as cancelled by making two thick diagonal lines across the form; writing CANCELLED in large capitals and the consultants’ signature and date. It should be filed in the back of the patient’s case notes. There should also be a clear entry in the patient’s case notes stating that the patient is now for CPR. The decision must be communicated to all relevant staff and recorded.

14.3 Community setting (General ops Barnsl e y BDU) The ultimate responsibility for a DNACPR decision rests with the GP in charge of the patient’s care.

In the absence of the GP the overall responsibility for making the DNACPR decision lies with the most senior clinician caring for the patient at that time

The GP with responsibility for the care should counter sign the DNACPR form within 72 working hours The senior clinician should complete the DNACPR pro forma and document the reason for decisions, conversations held with patient and significant others and review date in the medical no t es.

A GP or nurse should be identified with responsibility to inform the primary health care team and other health and social care professionals, including therapy staff and out of hour’s services of the decision. Records should be kept of these actions.

The review date will be agreed and brought forward under the following circumstances: a. DNACPR status is to be reviewed on transfer of medical responsibility (e.g. hospital to community or vice versa)

b. DNACPR status should be reviewed whenever there are significant changes in a patient’s condition.

An appropriate Professional should ensure that patient and/significant others caring for the patient are sensitively made aware of the purpose of the form. After patient and/or significant others have been informed of the DNACPR decision the nurse should ensure the completed DNACPR form is placed appropriately.

When the form is no longer valid, either because the patient is for CPR or because a new form has been started, it must be marked as cancelled by making two thick diagonal lines across the form; writing CANCELLED in large capitals and the consultants’/GP’s as appropriate signature and date. It should be removed from the home. There should also be a clear entry in the patient’s notes stating that the patient is now for CPR. The decision must be communicated to primary care and social care staff and out of hour’s providers and recorded.

The Procedure is dependent upon the patient’s clinical circumstances as identified below:

14.4 If it is not possible to anticipate circumstances where cardiopulmonary arrest might happen there is no clinical DNACPR decision to make.

a. Do not routinely initiate discussion about CPR with the patient or relevant others.

b. The patient and relevant others should be informed that they can have a discussion, or receive information, about any aspect of their treatment. If the patient wishes, this may include information about CPR and its likely success in different circumstances.

c. Review only when circumstances change.

d. In the event of an unexpected cardio-pulmonary arrest there should be a presumption that CPR would be carried out. e. No DNACPR form should be completed. f. If the patient wishes to make an advance decision to refuse treatment that he/she would not wish to have CPR in the event of an unanticipated arrest this should be explored in a sensitive and realistic manner by an experienced member of the clinical team. The patient should complete an advance decision to refuse treatment.

14.5 If It is possible to anticipate circumstances where cardio-pulmonary arrest seems likely for a particular patient then it is possible to make a decision in advance. a. If the patient is dying as a result of an irreversible condition, CPR would be of no clinical benefit and is not expected to be successful, it is inappropriate to offer it as a treatment option. b. Allow a natural death. c. Good palliative care should be in place to ensure a comfortable and peaceful time for the patient, with support for the relevant others. d. Ensure that the patient and relevant others as appropriate, are sensitively informed and understand as much information about their condition as they want and need (the reasons why CPR will not work may be part of this information). e Document the fact that CPR will not benefit the patient and the reason. f. Complete DNACPR form. g Where a patient is at home or being discharged home the primary care and out of hours team should be informed of this decision. The patient and/or their relevant others must be aware of the DNACPR decision and form. h. Review if medical circumstances change and if medical responsibility for the patient changes (e.g. patient discharged home from hospital)

14.6. If the patient is not dying as a result of an irreversible condition and if the team is as certain as it can be that CPR w o ul d realistically have a possibility of a medically successful outcome the next decision is whether the patient has capacity to take part in this discussion and fully comprehend the implications of the decision. a Adults should be presumed to have capacity unless there is evidence to the contrary. Evidence that a patient is suffering from depression, is under the influence of others or has any capacity issues would warrant a formal assessment of capacity. An assessment of capacity should relate to the specific decision the patient is being asked to make and their ability to fully comprehend their situation and the implications of their decision. b If the patient has capacity for this decision: Sensitive, honest and realistic discussion about CPR and its likely outcome must be offered to the patient by an experienced member of the clinical team unless the patient makes it clear they do not wish to have this discussion. This discussion must be recorded.

Continue to communicate progress to the patient and relevant others if the patient agrees.

C If the patient does not have capacity for this decision: The capacity assessment should be documented in the medical notes. If they have an appointed legal welfare attorney t h e y should be asked to make the decision for the patient in this situation with the help of sensitive and honest discussion with experienced members of the clinical team.

Where no legal welfare attorney has been appointed for the patient the clinical team should enquire about the patient’s previously expressed wishes from the relevant others. The clinical team have responsibility for making the most appropriate decision based on whether the benefits to the patient offered by CPR outweigh the likely burdens/harm created by the treatment as a ‘best interests’ decision. Continue to communicate progress to the relevant others.

d Document this discussion in the medical and nursing notes detailing the circumstances that any decision relates to and who was involved in the decision making process as a ‘best interests’ decision.

e If a DNACPR decision is made complete the DNACPR form

f Review regularly and if circumstances change.

14.7 When a patient with a DNACPR order is being transferred by Ambulance

a. The DNACPR form should be completed and should accompany the patient and handed over to clinical staff if the individual is admitted to hospital.

b. Ambulance control must be informed of the existence of the DNACPR decision at the time of ambulance booking.

c. Where appropriate the GP or District Nursing team should be contacted prior to discharge to discuss the DNACPR decision.

15 REFERENCES

Decisions relating to Cardio-pulmonary Resuscitation. A joint statement from the BMA, the Resuscitation Council (UK) and the RCN. October2014. BMA, RCN, Resuscitation Council UK Policy for the recognition and verification of deathLothian Do Not Attempt Resuscitation (DNACPR) policy (2007), Murray, Short, Spillar & Halliday, Lothian Health Board Scotland End of life care strategy (2008) Department of health UK Mental Capacity Act (2005) DOH. UK Healthy ambitions (2008) Yorkshire and Humber Strategic Health Authority UK Advance decisions to refuse treatment. A guide. (2009) Advance decisions to refuse treatment website www.adrtnhs.uk/eolc Regnard and Randall (2005) A Framework for making advance decisions on resuscitation Clinical Medicine Vol 5 No 4 Out of Hours Toolkit (2009) Macmillan Cancer Support/ Medicines Management Network. UK NHSLA Risk management Standards 2012/2013 SWYFT – Mental Capacity Act (2008) Treatment and Care towards the end of life: good practice in decision making, GMC May 2010 Court of Appeal DNACPR judgement in the case of Tracey v Cambridge University Hospitals NHS Foundation Trust 2014 Hempsons – Leading Health and Social Enterprise Solicitors, An issue or life or death ...., 19th June 2014 Appendix 1

Yorkshire and Humber DNACPR Form (example)

Equality impact assessment tool

To be completed and attached to any policy document when submitted to the Executive Management Team for consideration and approval.

Equality impact assessment questions: Evidence based answers & actions:

1 Name of the policy that you are Equality Do Not Attempt Cardio Pulmonary Impact Assessing Resuscitation Policy (D.N.A.C.P.R)

2 Describe the overall aim of your policy The aim is to ensure the safe secure and and context? legal handling of DNACPR decisions. Who will benefit from this policy? All patients/ service users, relevant others and staff members involved in end of life care.

3 Who is the overall lead for this Director of Nursing, clinical governance and assessment? safety

4 Who else was involved in conducting Simon Gillot - Specialist Resuscitation Officer this assessment? Janet Owen – End of Life Care Clinical Lead Dawn Thomas – Assistant Director of Nursing and Clinical Risk.

5 Have you involved and consulted Service user/carer representatives were service users, carers, and staff in consulted when the policy was first written. The developing this policy? TAG was also consulted What did you find out and how have you used this information?

6 What equality data have you used to No data due to low numbers of DNARCPR inform this equality impact assessment? forms in use. Low numbers would not provide any insight in to the diversity element of this policy

7 What does this data say?

8 Have you considered the potential for The TAG has considered this and ensured that unlawful direct or indirect discrimination the wording of the policy is not discriminatory to in relation to this policy? any one particular group

9 Taking into account the information Policy covers all staff working in SWYPFT and gathered. all service users who are in contact with Trust services. The policy will be implemented in the Does this policy affect one group less or same way for everyone regardless of more favourably than another on the individual’s diverse characteristics basis of: Equality impact assessment questions: Evidence based answers & actions:

YES NO

Race N Disability N Gender N Age N Sexual Orientation N Religion or Belief N Transgender N 10 What measures are you implementing The policy has been developed by a or already have in place to ensure that multidisciplinary group and circulated widely this policy: within the organisation for comment. There are currently very low numbers of DNACPR forms y promotes equality of opportunity, used. Use of DNACPR forms would not be y promotes good relations between recorded from an EIA perspective. different equality groups, y eliminates harassment and discrimination

11 Have you developed an Action Plan arising from this assessment? N/A If yes, then please attach any plans at the back of this template

12 Who will approve this assessment and Director of Nursing, clinical governance and when will you publish this assessment. safety and EMT

If you have identified a potential discriminatory impact of this policy, please refer it to the Director of Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the action required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact the Director of Corporate Development or Head of Involvement and Inclusion. Checklist for the review and approval of procedural document

To be completed and attached to any policy document when submitted to EMT for consideration and approval.

Yes/No/ Title of document being reviewed: Comments Unsure 1. Title Do not attempt CPR policy Is the title clear and unambiguous? Yes

Is it clear whether the document is a guideline, Yes policy, protocol or standard? Is it clear in the introduction whether this Yes document replaces or supersedes a previous document?

2. Rationale Are reasons for development of the document Yes stated? 3. Development Process Is the method described in brief? Yes Are people involved in the development Yes identified? Do you feel a reasonable attempt has been Yes made to ensure relevant expertise has been used?

Is there evidence of consultation with Yes EMT, Resus tag, , regional stakeholders and users? NACPR group, Solicitor comments provided to regional DNACPR group

4. Content Is the objective of the document clear? Yes

Is the target population clear and Yes unambiguous? Are the intended outcomes described? Yes Are the statements clear and unambiguous? Yes

5. Evidence Base Is the type of evidence to support the Yes document identified explicitly? Are key references cited? Yes Are the references cited in full? Yes Are supporting documents referenced? Yes

6. Approval

Yes/No/ Title of document being reviewed: Comments Unsure Does the document identify which Yes committee/group will approve it? If appropriate have the joint Human N/A Resources/staff side committee (or equivalent) approved the document?

7. Dissemination and Implementation Is there an outline/plan to identify how this will Yes be done? Does the plan include the necessary Yes training/support to ensure compliance? 8. Document Control Does the document identify where it will be Yes held? Have archiving arrangements for superseded Yes documents been addressed? 9. Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to Yes support the monitoring of compliance with and effectiveness of the document?

Is there a plan to review or audit compliance Yes with the document? 10. Review Date Is the review date identified? Yes

Is the frequency of review identified? If so is it Yes acceptable? 11. Overall Responsibility for the Document Is it clear who will be responsible Yes implementation and review of the document? Version control sheet

This sheet should provide a history of previous versions of the policy and changes made

Version Date Author Status Comment / changes Draft 1, Version 3 June Simon Gillott Draft Re-draft following SWYPFT format 2012 Janet Owen and incorporating SHA guidance Draft 1 version 4 Aug 2012 Simon Gillott Draft Inclusion of changes suggested by consultation across the organisation Final draft for Aug 2012 Simon Gillott/ Ann Final Minor wording changes, inclusion of EMT approval Hargate draft DNACPR form Revised document Dec 2013 Simon Gillott Revised Minor wording, changes re review date in line with changes Janet Owen documentin line with regional form guidance – in the regional form summary of form changes attached.

Reviewed in line Sept 2014 Simon Gillott Revised Minor wording, changes to include with Tracey v Janet Owen documentreference to Tracey v Cambridge Cambridge