LEARNING OUTCOMES
After completing this module, the paramedic will be able to:
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You have just started your afternoon shift and Ambulance Control (AC) assigns you to a transfer from the local hospital to a home setting. They inform you that it's a rapid discharge transfer for an end-of-life patient. You arrive at the palliative care ward and are met by the senior sister in charge who informs you that the patient has lung cancer, wishes to die at home and that this transfer is part of their advanced care plan. The patient called Benjamin is weak and cachectic, however smiles when you enter his room on the ward. You explain that you and your colleague are here to take him home, in respect of his wishes.
All documentation is present and you receive a full handover from the nursing team prior to leaving the ward, including where you should take Benjamin if he dies en-route to his home address. You are provided with a contact number for the ward should this occur.
Advanced care planning
Advanced care planning (ACP) is an essential part of end-of-life care for patients who are thought to be in the last 6–12 months of life (National End-of-Life Care Programme (NEoLCP), 2012). Effective, transparent and informative discussions and planning are essential to ensure that individual wishes are known and can be respected, and that people can die in a respectful and dignified manner, in familiar surroundings and in the company of family and friends. Ensuring that patients have control and autonomy over the decisions made at the end of their life will increase the chances that they will have what some authors describe as ‘a good death’ (Brady, 2013).
Dying at home
The majority of people do not wish to die in hospital—however, unfortunately, most do (Ingleton et al, 2009). Home is commonly the preferred place of care and death, and patients do not usually change their minds about this. However, this does happen in some circumstances (Public Health England, 2013).
Discussing ACP with patients
ACP is a voluntary process and there are various elements that should be discussed with patients: preferred priorities of care, do not attempt cardiopulmonary resuscitation (DNACPR) orders and advanced decisions to refuse treatment (ADRT), to name a few. It is essential that patients are aware of the full context of ACP so that discussions can be made about future care between the patient and care providers.
While the option to engage in ACP is voluntary, the opportunity should be available for everyone (National Palliative and End-of-life Care Partnership (NPELCP), 2015). A patient who has had discussions with care providers and created an advanced care plan explicitly highlighting their wishes has a higher likelihood of these being met (House of Commons Health Committee (HCHC), 2015).
Effective communication and coordination between individual care providers is vitally important to ensure that patients' wishes are respected throughout their care and when they die, as well as that families and loved ones are supported following the patient's death. Ambulance services play an increasingly key role in end-of-life care and this is especially true in terms of transfer of the dying patient (NEoLCP, 2012). This CPD article will explore ACP with a particular focus on DNACPRs, ADRTs and rapid discharge transfers.
DNACPRs
DNACPR orders form one part of ACP. Previously referred to as ‘do not resuscitate’ (DNR) and ‘do not attempt resuscitation’ (DNAR) orders, the term DNACPR has been standardised in order to ensure consistency and clarity of understanding. The term ‘resuscitation’ can be misinterpreted, however, with some clinicians taking it to mean that no treatment should be given (British Medical Association (BMA) et al, 2014). Implementation of the term DNACPR therefore ensures clarity and encompasses the following four aspects (BMA et al, 2014):
DNACPRs should be considered by health professionals when it is deemed that either resuscitation would be futile, or that the quality of life following resuscitation would be poor. They can also be considered as part of an advanced care plan and written at patient request where they do not want to be resuscitated (BMA et al, 2014; HCHC, 2015).
Patients and their family should be involved in discussions when DNACPRs are considered to ensure they are fully informed of the rationale and outcomes of CPR. However, while patients should be consulted, in some cases they may wish not to discuss dying and their wishes should be respected (BMA et al, 2014). Patients and relatives also have the right to a second opinion from another medical practitioner if they disagree with a DNACPR. It is vital that discussions take place regarding the reasons for a DNACPR and the likely outcome of a resuscitation attempt.
A DNACPR form should remain with the patient, with their personal details and the documented reason for the DNACPR. Situations of coincidence are not covered by a DNACPR; for example, if a person chokes on food and subsequently goes into cardiac arrest as a result of hypoxia, resuscitation should be undertaken as the cause is unrelated to the reason stated on the DNACPR form. Clinical judgement for this decision is required as the cardiac arrest is not in this instance caused by the documented condition (BMA et al, 2014). While DNACPRs should be adhered to as they form part of advanced care plans, they are not legally binding. If a patient does not wish for resuscitation to be attempted, an ADRT should be completed in order for this to become legally binding.
Paramedics may come across incidences whereby a person is at the end stages of their life and CPR would be deemed futile, but where no documentation or advanced care plan is in place. In these circumstances, the paramedic is fully justified to commence CPR and the initial presumption should be for resuscitation. However a clinician is also justified to withhold resuscitation if the wishes of the patient and relatives are known and CPR would be seen as futile (Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2016).
ADRTs
ADRTs form another part of ACP whereby an individual can forward-plan to refuse treatment at a time when they have lost mental capacity to make decisions (Leadership Alliance for the Care of Dying People (LACDP), 2014). ADRTs form part of the Mental Capacity Act 2005 and have the same legal standing as if a person with capacity was refusing treatment. Open and transparent discussions should occur between health professionals and patients about their preferences and decisions relating to treatment should they lose capacity in the future. ADRTs ensure that patients' wishes to refuse specific treatment are documented and can be respected. They cannot however be used to request specific treatment; only to refuse treatment, and in specific circumstances once the individual has lost capacity.
ADRTs can be written at any time, and individuals should be aware that while they cannot ‘go out of date’, if there are changes in treatments, medicine or other aspects of advancing clinical care, this in itself may result in an ADRT not being valid. For example, if advances in medicine lead to a change in treatment, it could be argued that had the individual known about this, they may have made a different decision. This is underpinned by the principles of informed consent whereby in order to make a fully autonomous and informed decision, a person should have all of the necessary information to make that decision. Anyone over the age of 18 can make an ADRT and this decision should be free from coercion (LACDP, 2014). An ADRT is legally binding when valid and applicable to the circumstances detailed within the document (LACDP, 2014).
If a paramedic is presented with an ADRT that is not valid, this document becomes an ‘advance statement of wishes’ (HCHC, 2015). While this is not legally binding, it can still be used to help inform decisions relating to the best interests of the patient. Paramedics must use information presented to them to help make decisions relating to the treatment of the patient in the given circumstances.
ADRTs are invalid while the person still has capacity and only come into effect once they are deemed to have lost capacity and are unable to make a decision. In these circumstances, a lack of capacity must be deemed by undertaking an assessment and never assumed. If the treatment refused could result in the person's death, the ADRT must be written with the inclusion of the statement ‘even if my life is at risk’. This should then be signed by the person followed by a witness.
ADRTs are legally binding and if a clinician acts against the recorded decision, they are accountable for their actions and could be liable for battery. Kirk et al (2017) found that while paramedics have high confidence in adhering to ADRTs and DNACPRs, concerns still arise with ensuring the validity of documentation when presented with these in practice. Across the UK, many areas have implemented unified regional DNACPR forms to help health professionals make decisions when attending patients at the end of life in these circumstances, and to reduce inconsistencies (NEoLCP, 2012).
Individuals may appoint a Lasting Power of Attorney (LPA) who can then make decisions on behalf of the patient with regards to their health and/or welfare matters. There are two types of LPA: one who can make decisions for financial matters, property and affairs; and one who can make decisions relating to health and wellbeing. If informed that a patient has appointed an LPA, it is important that healthcare clinicians clarify which of these they are. An individual can also be appointed an LPA for both health and financial affairs. An individual appointed an LPA which extends to life-sustaining treatment decisions must be explicit within the original application (HCHC, 2015). An LPA is legally appointed and consultation with a solicitor must occur.
Rapid discharge
Most people wish to die at home; however, as previously discussed, many do not (Pettifer and Bronnert, 2013). Predicting when someone will die is difficult and many factors can influence the timing of someone's death. Paramedics are frequently called to end-of-life patients and key decision-making is required to ensure the provision of high-quality care. For people who are identified as being within the last few hours or days of their lives, a rapid discharge transfer can be actioned to ensure they are swiftly transferred to the setting of their choice.
Kirk et al (2014) identified that only 51% of paramedics (n=182) in the UK knew about rapid discharge transfer processes. While specific policies and procedures will vary in different regions, the principles of rapid discharge transfers remain the same. Ambulance services play a key role in transferring patients from home to hospital, hospital to hospice, and from hospital to home (Department of Health and Social Care (DHSC), 2008).
If called to a rapid discharge transfer, on arrival at the unit/ward, it is important for the ambulance crew to establish the patient's status, care package, comfort measures and any advanced care plans in place. Transfer of care and clinical responsibility is essential, which requires a detailed handover and communication of care (NEoLCP, 2012). Prior to transfer, the attending crew should ensure they have the appropriate documentation, including any advanced care plans such as DNACPRs or ADRTs. It should be discussed where the crew should take the patient if the patient dies en route and a contact number should be provided for the crew to call in these instances.
Conclusion
Paramedics are frequently called to care for patients in the final stages of life and play a key role in ensuring patients receive high-quality care. Decision-making in these instances can be very challenging. It is essential therefore that clinicians have the necessary underpinning knowledge and understanding of the scope of ACP, as well as legal and ethical factors, that form the foundations for high-quality end-of-life care.