COVID-19 guidance on DNACPR and verification of death

See the Joint NMC/RCN statement regarding Decisions Relating to Cardiopulmonary Resuscitation (CPR) updated March 2020

Background

The primary goal of health care is to restore or maintain health, maximising benefit and minimising harm as much as possible. If treatment fails, leads to more harm or ceases to benefit the patient, that treatment is no longer justified, see British Medical Association, The Resuscitation Council (UK) and the Royal College of Nursing. All healthcare establishments have policies in place around cardiopulmonary resuscitation (CPR) and these should still be adhered to.

During the COVID-19 pandemic, some people will become critically ill and their clinical progress, or lack thereof, will prompt frequent review of their likelihood of benefitting from CPR. It is likely that, during the pandemic, more DNACPR decisions will be made for those critically unwell from COVID-19, based on clear clinical grounds that CPR would not be successful.

Do Not Attempt Cardio-pulmonary Resuscitation (DNACPR) recommendations are used to guide health and care professionals, across all settings, in making an immediate decision on how to respond should the patient in their care suffer a cardiac arrest or stop breathing for any reason. They may be made by clinicians or be put in place by individuals as part of advance care planning. DNACPR are not legally binding. Ultimately, the decision to start or not to start CPR is a clinical judgement made at the point in time; the presence of a DNACPR recommendation will guide this decision.

When clinicians are considering making a DNACPR recommendation there is a legal requirement for them to discuss this with the patient (or with those close to the patient who does not have capacity for that discussion. Guidance from the British Medical Association, The Resuscitation Council (UK) and the Royal College of Nursing underlines the importance of ensuring high-quality communication, decision making and recording in relation to decisions about CPR as an integral part of emergency care planning. 

In some health and care settings, DNACPR recommendations are recorded on a form that is specific only to a decision about CPR, many organisations and communities have moved to the use of broader emergency care plans such as Treatment Escalation Plans (TEPs).

An increasingly used example is the Resuscitation Council UK Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). ReSPECT is a process that gives clinicians and patients a framework to help discuss and support decision making for their care and treatment in a future emergency. The resulting clinical recommendations (which may include, for example, whether or not to be taken to hospital, whether or not to be admitted to ITU or placed on a ventilator) are recorded on a ReSPECT form, which also records a recommendation about starting CPR, or not.

Guidelines

See the RCN advanced decision making pages

Nurses can and do play an important part in discussing emergency care planning with individual patients. Recommendations about CPR and other emergency care and treatment should usually be made by or with the agreement of the senior responsible clinician, Nurses with the appropriate knowledge, skills and support may be the senior responsible clinician. They may also record an emergency care and/or DNACPR recommendations on behalf of the senior responsible clinician. 

The RCN expect that conversations relating to DNACPR recommendations should be part of a wider person-centred conversation with each patient, along with the wider team caring for the patient, where this is possible and appropriate to do. It is recognised that this may not be practical or possible to do in an emergency.

In some care settings, it is appropriate for the senior nurse to sign a recommendation about CPR. Guidance from the Resuscitation Council UK states that the senior responsible clinician should be informed at the earliest opportunity of the form’s completion if they themselves have not completed it. The senior responsible clinician should review and endorse the plan’s recommendation by adding their signature, or should review and have further discussion in order to revise the plan.

Where cardiac arrest or respiratory arrest occurs in a person before their emergency care plan or DNACPR recommendation has been discussed or endorsed by the senior responsible clinician, the plan can still be used to guide immediate decision making in line with the ReSPECT guidance.

Where cardiac arrest or respiratory arrest occurs in a person for whom there is no emergency plan or CPR recommendation in place, the clinicians present must make an immediate considered decision on whether or not to start CPR, based on available information. Whether or not a DNACPR recommendation is in place, a properly considered decision not to start CPR should be supported by senior colleagues, employers and professional bodies, local policies and procedures. See guidance from Hospice UK.

The RCN's clinical guidance for managing COVID-19 page has sections on palliative care and end of life and for ethical and rationing of services. 

Verification/Confirmation of death:

Verification of death is not simply a mechanistic task and sits within the broader scope of care after death. See guidance from Hospice UK. Standard infection control precautions are adequate when undertaking the verification procedure as per the COVID-19 IPC guidance. 

Nurses with appropriate competency can verify death. While nurses would normally only be asked to verify death when a DNACPR recommendation is present, the above guidance is also clear that any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies, local policies and procedures.

Verification of death means verification of the fact of death: this will be formally in line with national guidance, see here. Verification of death differs from certification of death, which is signing a death certificate; this can only be done by a medical practitioner. This will remain in the Coronavirus Bill: Managing the deceased but the doctor does not have to see the person in order to certify death. It will therefore, be more likely that nurses are called to verify death.

In normal circumstances, we would expect there to be confirmation within the patient record that death is expected, or that medical staff would appreciate nurse verification of death or for there to be a DNACPR recommendation. However, there is no legal requirement for this and, given the current situation, we recognise that it is likely that there may not always be such records in place.

We expect nurses verifying death to be trained and supported in the procedure and in the aftercare required by families and staff.

Resources to support practice

• BMJ editorial on Cardiopulmonary resuscitation after hospital admission with covid-19
• Joint NMC/RCN statement regarding Decisions Relating to Cardiopulmonary Resuscitation (CPR) updated March 2020
• RCN clinical guidance for managing COVID-19 page (go to sections on palliative care and end of life and for ethical and rationing of services)
• RCN guidance on confirmation of death
• RCN Remote consultations guidance under COVID-19 restrictions
• Hospice UK guidance
• Further guidance is available from the Resuscitation Council UK
• NHS England. Maintaining standards and quality of care in pressurised circumstances: Letter from Professor Stephen Powis
• Resuscitation Council UK guidance in relation to COVID-19 
• Resuscitation Council UK guidance for community settings
• Skills for Care. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). Respecting and protecting the rights and wishes of people.