Mark Taubert, Paul Buss, Steve Ham, Veronica Snow, James Norris, Ben Smith, Angela Jones, Rachel Lewis, Alan Buckle, Lesley Radley, Gwenllian Edwards, Mererid Evans, James Powell, Siwan Seaman, Velindre NHS Trust Patient Liaison Group and DNACPR Policy Implementation Group Wales
Velindre NHS Trust
Talking openly and knowledgeably about Do Not Attempt Cardiopulmonary Resuscitation Decisions in Palliative Illness.
The aim of this project is to improve communication and dialogue between patients with palliative and terminal illness and their healthcare professionals about Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions.
Four videos hosted on a website aim to describe some of the main areas to consider when discussing this important topic. Videos were co-directed by patients, in order for them to help explain relevant issues surrounding this sensitive subject. In addition, videos for healthcare professionals with guidance and tips on how to start these conversations sensitively and professionally are also available on the http://TalkCPR.wales website.
We also aimed to clarify some of the common misconceptions surrounding CPR, allowing natural death and DNACPR towards the end of life in a news article. This project is referenced in this Guardian article and can be found here: www.gu.com/p/4g5pv/stw.
This Project Supports Prudent Healthcare
- Public and professionals are equal partners through co-production: DNACPR discussions are some of the most sensitive and delicate in healthcare today. Many palliative care workers have experienced that patients want to be involved in these decisions and are not usually offended by their healthcare professional bringing this up. The TalkCPR videos and website encourage this dialogue, try to inform about the challenges of CPR and encourage open communication. They were made, produced and reviewed by patients and carers in Wales, and are all the more powerful for it.
- Care for those with the greatest health needs first: The videos are aimed at patients with palliative and life-limiting illness, as well as their carers and their healthcare professionals. There are tips on how to frame these conversations within the wider care that will be provided.
- Do only what is needed and do no harm: More should be done to prevent modern medicine from automatically defaulting to cardiopulmonary resuscitation in palliative care patients. Admission to hospitals and ITU in situations where a prior, honest and candid discussion with a seriously ill patient may have elicited that they would rather remain at home, are a missed opportunity. DNACPR forms do not preclude patients from very active treatment and the treatment ladder approach in the Top Tips video makes sure that only those procedures are considered that patients would feel appropriate, no more, no less. We checked carefully with our user groups that these videos were not insensitive or harmful, and in fact some responses felt that they could have been more explicit and blunt. But overall view was that we got the balance right.
- Reduce inappropriate variation through evidence-based approaches: Videos are being rolled out via the DNACPR implementation group to each Health Board and Trust in Wales and are also available on Howis. Two English Trusts have approached Public Health Wales and asked whether they could use the videos in their own setting, and Pulse magazine have written a feature for GPs in the UK, on this novel video and website approach to get patients and carers to take a lead on DNACPR. Videos are available in English and welsh and provisions have also been made for blind, partially sighted and deaf patients.
Communicating the concept of DNACPR in a sensitive way requires skill and once it has been discussed it should be documented very clearly, for other healthcare team members to know what discussion has been held. There is a need to explain this procedure better within society, and also to create reproducible ways of giving clinicians opportunities to gain confidence in talking about this topic more.
- Use of the new All Wales DNACPR form, which came into effect during 2015. This form is used to document communications between healthcare professionals, patients and carers.
- Acceptability and readiness of patients and healthcare professionals to use communication videos on this topic, to help understand what CPR actually is.
- Roll-out of the All Wales DNACPR Form across Wales, and its uptake and use as a communication tool between healthcare professionals, patients and carers.
- Roll-out of TalkCPR videos, four videos (all aimed at patients, carers and healthcare professionals) co-produced and co-directed by Dr Mark Taubert and stakeholders including patients and carers.
- DNACPR forms obtained from notes in late 2015 and early 2016 contained more information on communication between healthcare professionals, patients and carers than previous DNACPR forms.
- There was a significant increase in DNACPR forms that were demonstrably discussed with patients and/or proxy compared to previous years.
- TalkCPR videos were acceptable to both patients/proxy, nurses, and doctors and pre-and post-video surveys as well as focus-group results showed a high level of readiness to engage in DNACPR discussions, readiness to show information videos to patients and carers and a better level of understanding about what CPR actually means.
These short films have been made available in each health board and trust in Wales. Three English Trusts have asked permission to use the videos in their own setting, and Pulse magazine have written a feature for GPs in the UK, on this novel video and website approach. A media campaign has made the TalkCPR project very prominent in the public domain, with Benedict Cumberbatch reading out a letter at Hay Festival mentioning this NHS Wales project and a Guardian article on CPR which went viral. Both NICE and the GMC have published the TalkCPR website resource.
It is hoped that the use of video and website information for patients around difficult areas such as CPR wishes can inform part of a more sharing approach, allowing patients and their proxy to be involved in key decisions and providing good quality information.
Part of Cohort Bevan Exemplars 2015-16