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                                    Serving  Erie  St.Clair  &  SW  LHIN’s  

               

Frequently Asked Questions For Developing a Plan of Treatment Related to CPR

1. When should the discussion take place? Are there times within the system that highlight an opportunity to discuss CPR? Within the algorithm, Step 1 outlines possible scenarios that indicate the need to discuss CPR. If CPR is possible due to a progressive life limiting disease process, a high risk procedure or advanced age then the discussion should take place. (Box A) When to begin discussion on CPR with an individual and their family does require thought at any time. One would consider the trajectory of the illness and promote discussion and decision making prior to incapacity. Other factors that require consideration are the person’s current state(physical and emotional), time constraints of person, family and health care providers as well as other factors that enable a person to prepare for and engage in end of life tasks. Discussions about CPR are rarely isolated events. Information sharing related to person’s current and changing health condition throughout the illness is essential. A targeted discussion on CPR is within the context of the discussions about the person’s health and the implications for treatments including CPR. The health care provider must seriously reflect on his or her ability and comfort with the discussion when the discussion is unduly delayed. Within the healthcare system there may be points that prompt this discussion. Natural points at which to consider engaging in discussion of CPR include:

• diagnosed of a progressive life limiting illness • proposal of a serious surgical intervention with an uncertain prognosis • advanced age • application for placement in a long term care • planning for a death in the home

A person facing the need to move to long term care (LTC) generally has had a change in health status that prompts placement in LTC. The process of application usually involves reviewing the person’s circumstances/decisions. Since an admission to a LTC home sometimes involves a change in the most responsible physician, having the CPR discussion and involving providers who are familiar with the person’s situation as part of the placement coordination is advisable. Transfer trauma is a reality and though not frequent, death within 24 hours of admission to a new facility does happen. Pre planning will reduce confusion and distress in such cases. In the home setting an Expected Death in the Home (EDITH) plan includes this discussion taking place in advance of deterioration and potential incapacity. Early discussions enable the person to make informed decisions and treatment plans can be put in place.

2. What is the benefit of offering CPR in a long term care home given that homes do not have the same equipment that hospitals do? Offering CPR in a LTC home is the same as offering CPR in the public domain. If the physician is offering CPR as a treatment and the person has consented to have CPR, or if there is no plan in place and wishes are not known, the long term care home staff would initiate basic CPR and would call for an ambulance for transport in a cardiac arrest situation. Registered staff available 24/7 in a long term care home have the ability and responsibility to initiate basic life support (chest compression and artificial ventilation) until the ambulance arrives. When discussing CPR with residents and families, it should be made clear exactly what will happen in case of a cardiac arrest and that advanced life support is not available in the facility.

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3. How applicable is the process in the algorithm to treatments other than CPR? (e.g. tube feeding, hydration, etc.) The process for discussion outlined in the algorithm is an effective process for communication of information with the intent of eliciting any treatment decision. If one used box H interchangeably with discussion points on artificial hydration, tube feedings, antibiotics, blood transfusions etc., the structure outlined is valid as a thoughtful communication process for healthcare providers. The foundation of the algorithm process is based on the requirements for informed consent as required by the health care consent act.

4. Can you clarify how to interpret the hierarchy of substitute decision makers (SDM)? The hierarchy for substitute decision makers lists by rank those who may act as substitute decision maker when a person becomes incapable of making decisions for him/herself. (Box B) The hierarchy begins with appointed representatives. A. The Guardian of the person is a court sanctioned legal appointment. B. The attorney for personal care is a person who has been appointed by an individual to act on his or her behalf if

and when that individual becomes incapable. The legal document is called Power of Attorney for Personal Care. (POAPC)

C. Representative appointed by the Consent and Capacity Board through a legal application process. D. A person’s spouse or partner is next in the ranking if none of the above appointments apply. E. Parent or child or Children’s Aid Society (CAS). Please note that within this ranking parent and children have

equal status. F. Parent with right of access. G. Brother or sister (again note equal ranking). H. Any other relative by blood, marriage or adoption. I. Office of the Public Guardian and Trustee (OPGT) will make the decision if the person has no one higher on

hierarchy or if there is conflict between two equal ranking SDM’s. OPGT may look for relatives or friends willing to act as the SDM where possible.

Substitute Decision Maker’s come into effect only when the person becomes incapable of making the decision. SDM’s must be able and willing to act on the person’s behalf and make decisions/choices that are reflective of the person’s values and wishes and /or best interest. (Criteria listed in bottom half of box B) It is recommended that you become familiar with the Health Care Consent Act. The website is listed below. http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm These next sites are information documents from the Advocacy Center for the Elderly on the health care consent act and substitute decision making. http://www.advocacycentreelderly.org/pubs/poa/misconceptions.pdf http://www.advocacycentreelderly.org/pubs/poa/Consent_and_capacity_basics.pdf

5. Who is considered a spouse or a partner? Spouse in the Health Care Consent Act refers to two persons who are either married to each other, or are living in a conjugal relationship outside of marriage and have lived together for at least one year, are parents of a child or have a cohabitation agreement defined under section 53 of the Family Law Act. A spouse does not include persons who are living separately as a result of a breakdown in their relationship. A partner is either of two persons who have lived together for at least one year and have a close personal relationship that is of primary importance in both person’s lives. These definitions can be found in the Health Care Consent Act.

6. What about multiple children as substitute decision makers? You may face a situation where there are a number of children having to make decisions about their mother or father. By virtue of the Heath Care Consent Act, children have equal status if there is no spouse/partner or appointed representative that ranks higher in the hierarchy. It can challenge us as healthcare providers when all of the children

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act in the SDM role. The children should be guided by the health care team to reach consensus amongst themselves regarding how decision will be made. Some of the children may decline to act in the role of SDM and appoint someone to act as SDM. Remember a substitute decision maker must be willing and able to carry out the responsibilities. The reverse side of the CPR algorithm has an outline for conflict management that you can use in times of disagreement between family members. The Office of the Public Guardian and Trustees will act in situation where two or more equally ranked SDM’s are in conflict on a decision. They can be reached at 1-800-891-0504, ext. 2002. (London office) 1-800-387-2127 (urgent weekends and stat holidays only)

7. Can you expand on CPR Discussion Planning? (Box C) Box C is the next step in ensuring process, planning and responsibilities in this discussion. Box C in the algorithm is about determining the care team members to be included in the discussion related to CPR. The care team is comprised of the health care team members and the individual and his or her support system (family often). There needs to be a lead for the health care team that ensures that the discussion takes place, that the appropriate individuals( as identified by the person and the health care team) are invited to participate and that the specifics of the meeting and decisions are appropriately communicated. This is the 3rd step on the algorithm and takes place once it has been determined that cardiac arrest is possible and that there is someone (either the person or SDM) to provide informed consent.

8. What is the purple paper? (specific reference in the teaching DVD to level of care form) In Grey and Bruce counties the level of care form that has been used since 1999 is known as the “purple paper”. This is a level of care form with three levels, developed for communication and standardization between hospital, home, emergency services and long term care specific to Grey Bruce. In Chapter One of the video there is discussion on the “purple paper” (level of care form) in relation to its validity when seeking informed consent for treatment. There are many versions of level of care forms used across healthcare settings. Levels of Care forms generally speak to a person’s broader goals and wishes but do not meet the requirements necessary for informed consent related to specific treatments. Each specific treatment intervention such as CPR, requires that health care providers get informed consent prior to initiating the treatment. Levels of care forms may have some value in initiating sensitive discussions around generalized goals. In Ontario, consent for each specific treatment always comes from a person and not a piece of paper. Level of Care forms can help in the process but speak to the Substitute Decision Maker about a person’s broader goals . Levels of Care forms cannot be utilized by a health care provider as evidence of informed consent. In Grey Bruce the provincial adoption of the Do Not Resuscitate Confirmation form (DNR-C) provided an opportunity to review the documentation and discussion that should be in place for informed consent for the treatment CPR. The DNR-C form indicates that a plan of treatment is in place, that discussions reflective of informed consent have taken place with the person (the SDM if the person is not capable) and that there is documentation in the health record. The development of the plan of treatment for CPR and accompanying algorithm is a reflection of the process requirements of the health care consent act and completion of the DNR-C form.

9. What’s the difference between advance care planning and a plan of treatment? Advance Care Planning is a voluntary, personal process that enables an individual to articulate his or her goals and appoint a substitute decision maker. The goals, values, beliefs and wishes articulated in the advance care panning process speak to and guide the SDM in the decision making process. The health care provider utilizes the ACP with its articulated goals, values and wishes in discussing appropriate interventions at specific points in an illness trajectory in order to get informed consent related to the initiation, withholding or withdrawing of specific treatment interventions. Advance Care planning is the process that involves thinking about one’s future and clarifying and communicating your values and beliefs towards future care. Advance care planning is about making clear how you wish to be cared for, and giving someone you trust the authority to act on those wishes and values for you if the need arises.

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Advance care planning is about considering who to appoint as a substitute decision maker when unable to make decisions about personal care including healthcare, food, living arrangements and housing, clothing, hygiene and safety. A plan of treatment as defined by the Health Care Consent Act is a plan that a) Is developed by one or more health care practitioners b) Deals with one or more of the health problems that a person has and may in addition, deal with one or more of the

health problems that the person is likely to have in the future given the person’s current health condition and c) Provides for the administration to the person of various treatments or courses of treatment and may, in addition,

provide for the withholding or withdrawal of treatment in light of the person’s current health condition.

The Act stipulates that there is no treatment without consent except in an emergency situation. In an emergency, healthcare providers would follow the known wishes of a person with respect to treatment but if wishes are not known then emergency care providers will ere on the side of life and administer CPR. In Ontario it is required to get informed consent from the person or their SDM in any plan of treatment based on their current condition. (Box E) There is a variety of language and terms used such as living wills, health directives and advance directives that causes confusion for the public and health care providers. This algorithm and DVD is based on what governs healthcare practice in the province of Ontario. Consent is not a stagnant process and people, conditions and circumstances do change. Consent and confirmation is an active process and requires returning to the person or SDM as the health care status changes.

10. Who decides whether CPR should be offered? Offering CPR is within the purview of the physician. The College of Physicians and Surgeons of Ontario (CPSO) policy speaks to the physician assessment related to CPR. (Box G) Policy #1-06 talks about the three potential outcomes from the assessment of an individual as being: a) Patient is likely to benefit b) Benefit to patient is unlikely or uncertain c) Patient almost certainly will not benefit Box D on the algorithm provides reference to the guiding principles of when CPR can be considered to be an inappropriate treatment option. The healthcare team brings medical knowledge and skill to discussions of a person’s care and appropriate treatment plans. Clarity of communication regarding what is or is not a treatment option in each specific case is important. Discussion should happen in advance where possible and should provide clear, full explanations. Individuals and their families often interpret offering of a treatment by a physician as a recommendations for the treatment.

11. How should you define end of life care and allowing natural death in the context of a discussion around CPR? The discussion within the algorithm relates to the decision of CPR or no CPR. In the course of the discussion you would outline the details (i.e. if CPR is the decision then this is what will happen and if no CPR then this is what will take place). Reassurances should be shared that care will be given that addresses the person’s goals for comfort and the physical, emotional and spiritual needs. CPR will not help those whom are at the natural end of their lives due to a progressive life limiting illness. No CPR decision is not about withholding care and other treatments that may prolong life or abandoning the person and family. The reassurances and support for good care as the illness progresses and at end of life should be reiterated within the discussion and Box H includes these points. Describing what end of life care looks like is specific to each setting (e.g. LTC, Home, Hospital). It is site and provider specific as to what palliative care is being offered but it is also broad in terms of the goals of good hospice palliative care. The CPR discussion itself is clear in that it seeks a yes or no answer. The CPR discussion as outlines is reflective of the requirements of healthcare providers in getting informed consent for a specific treatment. There are conversations within the healthcare community about using the language of “allow natural death” in place of wording such as “do not resuscitate”. Using the language of allow natural death encourages the view that death be seen as a natural part of life. Wording and language is important to assisting in understanding and clarity with individuals and families. The treatment is specifically about CPR as a medical treatment and this is in the language to

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engage in with families in this specific treatment discussion. Combining the language appropriately within the discussion is what is being advocated and the use of natural death is included in the discussion points. (point 4 in Box H).

12. How should discussions with residents, substitute decision makers, and families be documented? On the DVD there is a resource chapter which includes a template that was developed in Grey Bruce for documenting the plan of treatment for CPR. This document is for reference purposes and is offered as one potential way to document this discussion. The document includes the steps of the process necessary to comply with the health care consent act. Communication and documentation are critical elements of the process. Documentation should be reflective of our professional requirements, agency and facility policy and consider the elements of informed consent. (Box E)

13. How should a heath care provider deal with situations when a person’s capacity varies day-by-day? Determining capacity is step 2 in the process (Box A) and in situations where capacity fluctuates there may be several considerations and approaches to take.

• assessment of the persons capacity would aid in garnering consent in the best possible circumstances. • consider when to have the discussion (i.e. time of day), • ensure team is organized for times of lucidity, • involve the family and/or substitute decision maker in information sharing and care planning

A person is capable of providing consent if she or he is able understand the information that is relevant to making a decision concerning the CPR treatment and is able to appreciate the reasonably foreseeable consequences of a decision or lack of decision regarding CPR treatment. (Box A) The ability to make decisions varies with the decision and its complexity.

14. If a person is cognitively impaired, does that mean he/she is necessarily incapable? Determining capacity is the role of the healthcare provider when seeking informed consent for any treatment. Assessment is ongoing and the ability to make decisions can vary with one’s condition, from month to month, week to week, day to day etc. Decisions have varying degrees of complexity so people may be capable for one decision and not another decision based on that complexity. Having support people present whom know the person to assist in the information sharing and the individuals understanding and appreciation can assist with the decision making process for that person. Cognitive impairment does not necessarily mean a lack of capacity to appreciate and understand the consequences of all decisions about one’s health care. Capacity can be assessed on the basis of the specific treatment intervention being proposed. Capable to consent as stated means giving informed consent in relation to your condition and the recommended treatment. It includes understanding the alternatives to the proposed treatment, and likely outcomes of either accepting or refusing the treatment. A developmental disability, a psychiatric disorder and some stages of a progressive disease such as Alzheimer’s do not preclude making decisions about one’s own care. Making decisions early in a progressive illness may assist in your wishes being carried out when you do become incapable. Decision making requires ongoing assessment and confirmation.

15. How can a health care provider determine whether a person is capable of the treatment decision re: CPR? Determining capacity is the assessment of the person’s understanding and appreciation of the information discussed in regard to the treatment of CPR by the healthcare provider. The healthcare provider shares the information and checks in with the person as to the understanding. Ask the person to tell you what you have just explained in his or her own words. The person is to demonstrate an understanding and appreciation of what CPR is and the consequences of the decision. Capacity should not be judged by agreement or disagreement with the health care provider’s recommendation but by the person’s understanding of the treatment and appreciation os the consequences of the decision.

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16. What if there is no physician?

I f the person is an orphaned patient or there is not a designated responsible physician, the nurse can proceed with the steps in the algorithm as if CPR is being offered. The nurse can engage in the decision making process of getting informed consent to either include or not include CPR in the current plan of treatment. (Discussion points as outlined in Box H) In the absence of a physician assessment the nurse involved can consider consulting with the team in regards to recommendations. It is noted that an individual and their family will often ask for an opinion with any proposed treatment and that they value that opinion in their decision making.

17. How should a health care provider deal with situations where a family member attempts to overrule the wishes of a person that is capable? In situations such as the one described in the question above, there is an opportunity to utilize the conflict resolution algorithm as outlined on the reverse side of the CPR algorithm. Efforts should be made to advocate and share what you understand to be the person’s wishes. You should discuss with the family member the meaning of capacity, consent, substitute decision making and how treatment decisions are made. Conflict resolution includes ensuring the understanding of the person’s condition and the implications of the illness, treatment of CPR including risks and benefits for this person. Within the resolution process one may also solicit a second opinion from another physician. As healthcare providers, we have an obligation to acquire consent for each individual treatment from a capable person. If a person with a progressive illness has consented to withholding or withdrawing a treatment based on his or her current condition, the consent continues to guide the health care provider’s care of the person even if that person becomes incapable. Substitute decision makers are required under the law to execute the last know wishes of the person whenever possible or to act in the person’s best interest if wishes are unknown. An application can be made to the Consent and Capacity Board to direct a SDM to follow the known wishes of a patient or act in the person’s best interest or otherwise be removed.