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Neurosurgeon. Right? But I've just finished a blocks on geriatrics, emergency medicine, as well as general medicine and, um, general surgery. So today I'm going to do a very short talk on D N A C P R and a wi forms. It's only about 20 minutes or so if you can bear with me. Um, let me just see. So what I'm going to cover today is what both D N A C P R and a wi forms are, what your role is at an F Y one and Fy two level, how you feel the might and how you go about having the conversations and assessments in order to fill them out in any legal issues to be aware of. So this is the D N A C P R form. I've put two on because in the left is the one I'm more familiar with, um, that you probably have saw about. And the one on the right is one I think they're bringing in that's new, that's recently turned up in the words, but they're both pretty similar and you do them exactly the same way, um, to fill the might, it's the same as all forms at the very top. Always make sure you have your patient label and identifying information on the left with box A and box be, it can be a bit wordy. But what most seniors have told me is just always feel like box A which is CPR will not be successful and there's not a treatment option for this patient. Um And the reasons why you either list there multiple comorbidities or sometimes you can even just write the world free the word fealty in there. Um What is important is the box to tick about the conversation that you've had either with the patient or the relatives and to make sure this is clearly documented in the notes. Um, just for legal reasons, you need to make sure you've tried to your best to inform a family that this is in place if it is in an emergency situation, say, as long as you've documented a reasonable attempts to contact, that's also acceptable and you would still put the form in. And also just to say why you haven't told the patient if that's the case, whether that's because they lack capacity or whether it's a judgment of harm to a patient, which is usually a more senior decision or someone again has a mental condition that you think this might harm them and always make sure if there's a power of attorney that they're aware. Um, the form of the right is exactly the same except maybe a little bit more clear of wording if the first box is just CPR is unlikely to be successful duty. Um Okay. And this is just the box at the bottom where you sign, um, it's important to note as F Y ones, you aren't allowed to sign these forms because you don't yet have a full GM see registration. So only an F two can you fill the might but why it's still relevant to yourselves is because in a lot of hospitals and me myself, um as F one's, we were asked to have the conversations with the patient of the relative clearly documented in the notes. And then the senior consultant would just come along and do the signature um underneath the junior doctor's signature is where the consultant would sign, that's usually supposed to be done within 72 hours at the first signature. Um And the only time where it might differ is if you're having a conversation and the patient or relative disagree and they want resuscitation, but you, the medical team don't think it's in their best interests, you need to consultant opinions um to make sure that everyone is in agreement that this should be in place, obviously out of virus, that is impossible. But if it's still an acute situation where the patient might die and the next few hours or day, um I would recommend discussing with your registrar and even if they don't have the time to come down and sign the form themselves as long as you clearly documented that you've discussed it with them and that they agree when should be in place, it covers yourself for incidents where the next day the consultant comes in and actually says we should have done CPR when we didn't. Um, it's just, I said it's very important to fill out these forms because, and if, and discuss it with the family as if you don't discuss it with the family, this form can't go home with the patient. Um and therefore will be useful if they become unwell in the community in the same context. It's important to make sure on when you're writing your discharge letters. If one of these have been put in place during the admission to let the G P know that so they can update portal or you yourself can update portal. Um just so like paramedics who come to a patient out of hospital know that this is in place and to not start CPR and just prevent unnecessary treatments, okay. This is just the backs of the forms. They're pretty self explanatory the top where it says review of decision. I've never been involved in that. That's usually seniors. Um the bottom bit where it says communication with ambulance crew, you'll often get paged as Fy wants to come and fill this out because the patient can't go home without it filled out. But as it says in the form and just a lot of staff aren't aware, this can be filled out by any nursing or health professional. It's just basic patient information. So you do not need to answer a page to come do that. But obviously you can if you're just on the board. Um okay and deciding when D N A C P R would be appropriate. Uh Well, this is in context of an acutely unwell patient versus way in someone's towards the end of life. And a more opportunistic discussion at Fy one, um you'll more likely be involved in the opportunistic discussion. So that's a patient on the ward round that your consultant just thinks one would be relevant, but they're not currently um at risk of passing, but sometimes you will also have to have the acutely unwell but less likely enough. One, definitely an F two. So that's why I still think it's good practice to have the opportunistic discussion's when you can and you're supported an F one. So it gets the time of having that discussion with the patient in recess where is imminently dying and it's very emotional and stressful for the family that you're more equipped to have the conversation. Um Just makes everything easier things to consider when deciding if you should be thinking of putting one in. Often. The first thing you look at is comorbidities and past medical history. Um Things like end stage COPD, severe heart failure, severe dementia, all these things make someone's ability to survive or have a successful resuscitation, much worse and their outcomes and quality of life as well. And free LTE itself can be something and when you're deciding whether it should be put in, each alone should be, can be looked at, but there is no cut off. Everyone needs to be looked at an individual circumstance. Um And, and if you don't have enough information from the past medical history before you start your D N A C P R discussion, it's often good to get a good social history from the patient or the relatives. Things that would be important would be whether they're high spined, whether they have what their exercise tolerance is. For example, if they can only walk 3 m, um like how far they can walk. So if they only can walk 3 m due to shortness of breath because of the COPD, that's relevant. But I guess less relevant if they can only walk a few meters because they're waiting for a knee replacement or if some muscular injury, um the bottom two, which is cancers or young Friel patient's which or genetic conditions, I'd often say it's important to consider that a DNA CPR might be relevant. But at a foundation level, we aren't really required to make those decisions alone. We should be asking our seniors or specialists whether one would be relevant. For example, a lot of cancers, a lot of oncologists revoke D N A C P R s because they think this won't kill the patient or it's curable or they'll die from something else. So it's just more to, it's good to consider all these things even at F one. So if you're reviewing someone who's on whale out of ours, you can let your registrar know they need to come up to sign one of these forms. Well, if you don't have it on your mind, you can also, you can often get distracted by someone who's very unwell and using highly. But this is, this is important in case they arrest and then you have to start CPR one. And actually, in reality, it's not in the patient's best interests. Uh And this is just a general template I use for doing DNA CPR conversations, but everyone develops their own way and their own phrases and that's why it's good to practice to just see what suits yourself. I'll go through this just as a general guide. Um I usually start by explaining the current management and treatments were doing for the patient just to make it clear that we are doing everything we can to make them better. And then I would often broach the topic by say, if they're acutely unwell saying something like sometimes when people becoming well, we've got to think about what would happen if these treatments don't work or if you're having the more opportunistic discussion, it could be sometimes when people come into hospital, we try to plan for what would happen if they became more and well, or if they became more and well in the future. But you can emphasize that this isn't something you're expecting to happen now or soon. But just it's good to plan these things. When you recognize someone has been into hospital a few times this year, there are chances of surviving another year's greatly reduced. And then I would usually bring up the topic by saying, has anyone ever discussed resuscitation with you or your relative? And you'll get very different answers to this. Some people will just say yes, I don't want it and you'll stop your conversation there. Um But other people will, a lot of people will say no, this has never been talked to them. Um And then you need to try and see what their ideas of CPR is because a lot of people today of misconceptions from TV about how successful and the realities of what it is. Um So then I would go on to explain what CPR resuscitation is and get across the point. This is quite a traumatic thing that can often result in a loss of dignity for the patient or I use where it's like aggressive, pointing in the chest or brutal or invasive just to make it clear, this is not, not a nice thing. And if it's not needed is something that's much better for the family and the patient. Um Then I often mentioned statistics of success and talk about quality of life. So I think it's less than a quarter of people survive hospital discharge and of those people, they all don't have the same quality of life. Um And that's an emphasize that is involving the fitter, younger patient's as opposed to someone like yourself or like your relative that's already quite friel. Um And then sometimes I'll say, um we're talking about quality of life that we often have to pass a tube into their windpipe and put them on a ventilator. And sometimes it can be viewed as prolonging their death rather than prolonging life. Um I always think it's very important with all these conversations to emphasize this doesn't affect emergency treatment right up until the heart stops. Um, that you're going to do everything in your prior to make sure they're relatively themselves, do not, do not pass and do not become more and well. But, and also emphasize, this is not a palliative thing. People often think of DNA CPR means we're just withdrawing all treatment, which is not the case and you'd be surprised that people that go away with the wrong ideas in their head. One thing you often do get in these conversations is either relatives saying that, oh, they'd like to go home and have a think about it and talk it over with their families, especially in acutely unwell situation. This can't act, this isn't what can happen. It has to make it very clear that D N A C P R s is a medical decision rather than a patient or family decision and they can reject refuse CPR, but they cannot um they cannot request it. So one way I try to say this is we wouldn't offer a patient surgery if we didn't think it would be successful or in their best interests. Or sometimes you can say we make this decision as healthcare professionals to try and take the onus off of yourselves. And again, if you're getting people that just outright don't agree and they want CPR for themselves, their relatives just always discuss with the senior, get a second opinion written down or get, get your consultant if it's in ours because you don't want to put one of these in place if it does become a legal issue. Um, but as I said, if it is out of IRS, just get your registrar to back you up. 15. Uh huh. That's DNA CPR covered. Um, I was going to do a little bit on a wi which is adult so thin capacity. This is adults, people age 16 years or over who lacked capacity to make some or all decisions for themselves because of a mental disorder or an inability to communicate. Um, not going to spend as long on this because to begin with an F Y one level, you are allowed to fully site for the same reason that you need a full GM, see, license. And even then when you are feeling the might in F two, there's a lot less, they're a lot less contended, a lot less legal issues, a lot simpler to fill out. Um, but it's still good to be aware that as an F one that someone might need one of these. Um, so you can let your seniors. No. Um, how you assess capacity, I'm sure you are all aware from medical school. The four key steps that they must understand the information, retain it, way it up and communicate it back. Um Also important to note that capacity is a time and decision specific. That's their ability to make a specific decision at the appropriate time. Um For example, inability to make a major complex decision doesn't mean that they can't make smaller simpler decisions. An example, it's pretty simple example, will be someone may not be able to decide where they go to live when they leave hospital, but they may be able to decide what they have for dinner, say a bachelor or worse. I'm not some of the he he principles would be always presumed someone has capacity until proven otherwise. Um support the individual as best they can to make the decision whether that's involving a translator, say speech therapist, if someone's had a stroke and they have receptive dysphasia or get an advocate or next of kin in, and people are allowed to make unwise decisions as long as they're allowed to do these four things. Their decision doesn't make sense to you as long as they can do this, that is fine and you must act in their best wishes and the least restrictive option. This are, these are the forms for a wi it's pretty self explanatory how to fill it out. Um Anything to note would be for how many months it's relevant for, it really depends what the reason for their incapacity is. It could be something from delirium too, dementia, traumatic brain injury, receptive dysphasia, mental health, low G C S. Um But for example, if someone has delirium, you might just write a month, but if someone has severe dementia, you might pay a year and and on the right is something the hospital adds to the forum just to make specific decisions clear which they can and cannot make. You can either just leave it as it is or sometimes they do prefer it if you write in the specific things that they're not allowed to not be able to decide themselves such as getting bloods or getting fluids or antibiotics and things. Um And it's always important that you let the power of attorney know that one of these is in place and then the next of kin, but it's not as time set as, as time sensitive as the D N A C P R. Mhm And that's me finished. So if anyone has any questions at all, I'm happy to answer or if you could fill in the feedback link, that would be great. Mhm. Um Perfect. Yeah. If you could feel like the feedback form that's really helpful, you'll find when you come to do your rcps next year and the year after you need all these forms. Two. Okay. Oh, sorry, I'm seeing the question about mentioning about stopping the discussion to any CPR if it has been discussed with the patient um and asking about their decision from the previous talk. Um Sorry if I've misunderstood Juba, if you mean what I might have just not been clear. So I meant sometimes the conversations a lot easier as people have already decided, they don't want resuscitation. So all your spiels that come after that you don't need to and there and then, then you start to agree about putting the form in and you just explain to them what the form is, what it means still, that we're not withdrawing treatment and that it will go home with the patient because it's being discussed or if they've already had a discussion and the DNA CPR is already in place and it still hasn't been revoked. Usually that's just printed out and put in, put in the patient's notes. Um So then you wouldn't have to have a re discussion, I guess in the acute senses, a junior doctor, if one is already in place and hasn't been invoked by the G P, I usually wouldn't go into a day, any CPR conversation again. But I guess it would depend how long ago that discussion was because some people do forget that we talked about this in a previous admission and it's still relevant. Now, the document would still be valid, but sometimes, especially with relatives when you're talking, just giving updates in general, uh, that they might pass soon, you could have this conversation again and just remind them that this is in place. Um I have came across it before where someone has it in and they got emotional when I brought it up because I assumed it was already in place and discussed which it was. But I think just with the new cancer diagnosis, they get very emotional. So it is always best to still go about the conversation in a sensitive way. Even if you think they've had the discussion before, I don't know if that answers the question. But also I just recommend speaking to your seniors, like even people more senior than myself will have lots of good ways of phrasing this. And in your first DNA CPR conversation, your senior should support you and you can practice what you're going to say before you go in and say it to the patient or they can come with as well sometimes because getting all collecting a listening to everyone else, how they do it and then deciding how you want to, we'll just be something that comes to practice and everyone's different. Is that any more questions over there? Okay. I think I'll end it there then if there's some more questions. Thanks for coming.