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We have a final speaker today um who is uh Doctor Gregory mcneal. So Gregor has is unfortunately unable to join us um this afternoon um due to other commitments um but he has recorded um a video for us um on what his talk was going to be. Anyway, um He is um if you don't know, Gregor Gregor is the National Clinical Lead um for Health Improvement, Scotland's SP sp Acute Adult Program, looking at the deteriorating patient. He's also a consultant intensive ist in um the Royal Infirmary in Edinburgh. Um He is going to speak to us about D N A C P R. He is going to cover that aspect of it, looking at current problems and uh future solutions. Um So there are also an ability for questions that they are not to Gregor but to the rest of us and we will then go into the panel discussion as well. So I am going to try and make this play and see if the technology works as it should do. And I'm going to speak to you today about DNA CPR current problems and future solutions. As I said, my name is Gregory mcneal. I'm a consultant, credible care here in a Chess Lothian, working predominantly the role for me in Edinburgh. Um I um my other kind of probably uh declaration of interest is that I am uh the SP sp lead for acute adult within the health improvement Scotland. And that means I have kind of uh lead quality improvement work within the kind of deteriorating patient work stream. So I have some uh skin in the game when it comes to kind of things like Teppei CP, etcetera. From that point of view, I'm speaking to you very much today with my own personal views on what I see is the way forward. So what we're going to unpack over the next 20 minutes? Well, um I'd like to really just get you to think about the context about we how and when we make our DNA CPR decisions and you know, the where healthcare is at the moment, I'm going to talk to you about some specific aspects of the DNA CPR form. Once we've done that, we'll just kind of scoop out future solutions. And what, what does it, what, what the future may hold um whether treatment escalation plans have uh show us a way forward for this work and, and, and, and just some thoughts on what, you know, when National Guidance is useful when it's not. So my own personal context for this and this has happened not once but twice now is um conversations with taxi drivers. So I don't get many taxis, but I do often if I'm going to the airport and someone else is paying, I will get a taxi and on two occasions, on early morning 12 up to Edinburgh airport, I've had a conversation with a taxi driver and, and they've said, you know, what, what you do have sort of a, I'm a doctor in intensive care. There's usually been some chat about how, how tough the pandemic was and then it goes on and it spills on and the test driver says, um, do you know why my mom was called up? My mom was called up by a healthcare person and they were told that they wanted to make them D N A R and I was shocked and my mom was shocked and we were disgruntled. We were unhappy, same conversation again a couple of months later. And that made me think, it made me think that these conversations aren't always going well and we're maybe trying to do something that's just not working and maybe it's because we're trying to have the wrong conversation. That's not necessary what we're, what that healthcare worker was calling up the mom to really discuss if they really thought about it unless I'm part a little bit more. And certainly the, the conversation left that patient and by extension, clearly, her relatives feeling that well, actually, the healthcare system doesn't care about me. You don't care. Just want to not do something. And why did that conversation not go go well. And it may actually be that actually the reason that healthcare worker was calling up, that patient was sure they were in actuality asking about DNA CPR. But actually they were doing that because they wanted to use that decision as a surrogate to decide uh other stuff. So the conversation wasn't really joined up. Let's unpack that a bit more. We all know that uh our healthcare systems under are under tremendous strain right now. Unprecedented strain. It's almost impossible. We all noticed to get appointment, our GPS, my wife's a G P. So I can say that um if we get seriously ill, it may be a delay in the ambulance getting to us once the ambulance arrives and we have to wait in the need before it can unload us. When we sit in the emergency department. We're likely to be sitting in a trolley or we may have to wait something in my board upwards of 40 hours routinely to get onto a ward if we need admitted. So clearly, the healthcare system is under strain, the public feel that um and, and uh and people I think genuinely worried that we're having these conversations because we're trying to uh cut them off. Um And that's obviously not the case, but why is the conversations we're having? Not, not the right ones. Well, that, that, that's something we need to think about another aspect of this is um expectations because on one side were telling the public were overwrought we can cope. But another side of us, sometimes it's coming from the same people in a difference that they were saying how amazing healthcare is and what we can achieve. And some kid weighs healthcare is a meeting what we can achieve with modern techniques. And we rightly want to show to go to as we try to advance clear in invade challenging circumstances. And it's been known for a long time that patient's perceptions of what can be done um in some ways are very different from, from reality. Um There is a paper published in 1996 which shows 75% Roscoe uh for um cardiac arrest displayed in uh um in, in TV dramas. It's not uncommon to see the patient waking up and sitting up quite a thing afterwards. Even if we look at the published evidence around reality TV shows relating to healthcare themes, everything is very skewed. You're far more likely to see a traumatic cardiac arrest. Your farm would like to see trauma per se. You're far less likely to see what the majority of arrest that we see and uh the outcomes or seeing care delivered such as CPR to a frail population where it may not benefit them that is not really covered in um in media, not the evidence would support that. And we rightly want to shout about the things we do that are amazing. And there's a lot of amazing stuff out there. We were very lucky to work in healthcare. You know, the reason why I'm an intensive care consultant is because I like delivering complex therapy to save lives. Um And you know, this picture here, this is um you can probably see that this is the Eiffel Tower. This is a picture from last week. Um The this involves a patient who had uh resistant VT uh with loss of output on the middle deck of the Eiffel Tower. And um the SAMU team, the amounts of team in Paris came, attended to the patient. One of the doctors who seconded doing um an educational secondment with the team is our very own. Doctor Hartley, who those in Glasgow, uh Edinburgh and Aberdeen may know Doctor Hartley is a consultant in the Royal in Edinburgh and that is uh Doctor Hartley and a colleague placing that patient on ECMO E CPR successfully patient transferred to local hospital. Three stents later, the patient wakes up. That is amazing. That is, that is amazing. It uh it made the Parisian local news that, that he think and um you know, the public see that, oh, they can really do amazing stuff. But clearly this is a very specific situation, a very specific circumstance, but you can see almost as a relative or a patient. Remember the public, the confirmation bias, this is going to give you this. Oh my goodness, they can do this for me and I have my, am I uh some years from now and it's gonna lead to confusion, confusion of our patient's, uh, confusion for their relatives, but possibly the main problem. And I kind of slightly alluded to this already. The main problem with our CPR, our DNA CPR forms is, it's not an honest discussion. We all know as healthcare providers once a patient dies, that is generally it, they are dead. And we all know that CPR um is not very effective unless it's a specific circumstance, you know, in CCU post M I highly monitored environment, then it may help but largely it doesn't. But we're using that D N A C P R form as a surrogate to decide other things. So we're not really having an honest discussion with our patient's. The reason that there's such a push to do DNA CPR forms is we really want to know what, when are we going to be offering these patient's advanced therapies such as admission's critical care? When are we going to think about antibiotics? When are we going to think about instituting palliative care? When are we going to do invasive things like CPAP N I V, invasive ventilation are tea, all that stuff. That's what we actually want to talk about. We all know as healthcare providers once you're dead, you're generally dead. So the premise of taking that form to a patient entering to that conversation is um it's not uh it's not necessarily as honest and as clear as we could be. And we need to give clear information. Now we go into these conversations because we want to create a treatment escalation plan. But I think the form is this red form is pushing us to have a focus on DNA CPR breath. Actually, the other stuff is far, far more important. So we focus, the form makes us focus on this act. This act that we do when a patient has died. And actually what we need to focus on is not the bits in that form. It's the bits and the treatment escalation plan because these are the beds, the harms or the benefits. We can give a patient in life that are more important. We want to think with the family, with the patient about whether they would benefit from noninvasive ventilation. We want to think with the family and the patient but whether they benefit from invasive ventilation, feel care, admission. These are my biases. But for you working award, it maybe are they going to benefit from antibiotics? Are they going to benefit um from palliative care. Should a deterioration occur when that's what the conversation needs to be about? What you know, who cares once they're arrested and died. Um That may need to be referred to at some degree. We Smith still may need to make a decision about that, but it should be a tiny bit of the conversation, the least important bit of the conversation you could argue. So we need to be uh as honest as we can be because we all know that once kind of crest occurs, the ship has sailed. Um And, and therefore that conversation is the least important. Bet it's what are we going to do for this patient in life or the benefits we can give that patient in life or the harms that we can avoid in life and everything we say and everything we um develop and, and put out there in, in terms of the health improvement, Scotland, SP SP is about being as patient centered as we can be. And the patient centered conversation is about the things that we're going to do for that patient. Uh when they're alive to avoid harms and when they're alive, clearly, CPR can be harmful to a body. It is great in dignity. We, we also want to maintain a mechanism where we don't start to do that inappropriately. But if we focus too much on that aspect of care, we risk generating harms in life. So where do we go from here? Well, um I in my role within SP sp very lucky to have been able to chair the update for the sign 1 39 guideline dealing with care of the deteriorating patient. Some of you may have seen that it's been out for consultation, that consultation is now closed. We hope um that uh this guideline will be launched and published uh mid mid June this year. Now, um I can give you the the details of, of, of all all all the details of this document clearly at the moment until it is published. But I can say to you that it will cover primary and secondary care and it will make clear recommendations about the use of TEP and anticipated care planning. And we'll also comment on the use of uh D N A C P R in that context. And, and we hope that will be useful for all because what boards have to do is consider sign guidance and what the wider healthcare system has gone has to do is consider sign guidance. So uh watch this space on that and I'm sure I can't share any more detail on that at this moment in time. So, so that's the context. So hopefully, um I persuaded you that there needs to be some uh some change in emphasis. But what systems do we have in place already? Well, actually, um there's a lot that is good in terms of the processes we have in place because um many healthcare systems across the world do not have national guidance. Um Complete national guy counts on decision making regarding uh D N A C P R, they do not have one single form now we do. Um And this is it, it was published first in 2010. It was actually based on NHS Lothian's uh DNA CPR integrated Adult Policy, but it went national and it was updated further in 2016. And many healthcare systems think this is a great thing that we do have that 11 form for all. And we have National Guidance and it was produced by the Scottish government. But I think you can see from what we've we've discussed is that that conversation now is just far, far too narrow. And the risk is if we focus too much on daily A CPR, we forget the others. And I would argue more important bits of a treatment escalation plan or an anticipated care plan and the continuation of this form and it's now is narrow focus. Uh It does potentially risk harms and is out of step with our patient centred approach. So I think we do need to think about changing that approach and, and and reducing the emphasis on the D any CPR form and moving over to a treatment escalation plan uh for such as one here produced by Created Glasgow and Clyde because this is the conversation we need to have. This is the key bit and D N A C P R is just, or, or for CPR is uh just a small, um small part of that. Uh And actually, I think what the more the more challenging question is about how we do that. Um And that gets the debate about health delivery or generally is it right to have a single form for every board to use on a single policy or is there local nuance? I'm not going to give you an answer to that right now. I think that has to be picked out and the conversation has to be had by uh people from different perspectives. There are some strength in having one form for everyone. Um But people do have different opinions and contexts are, are different. So um there is also uh benefit from having a local Newell's as you can see on the panel on the left there, we've got a variety of uh tech forms. We got the track version from NHS Lothian Good in Glasgow, Clyde. One um Anxious Grampian uh moved across to attract care based one as well. But that is a a previous version of of tech form used NHS Grampian. So I said, I do know, but um uh we do have a national guidance around um a daily CPR form at the moment and, and I think that that is something that we need to look at and it may be that uh there has to be guidance around national use of the tet but not a single tet form that can be decided at local level. But these conversations have to be had and I'm sure I'm sure will be had had in, in due course. And I think what we're all trying to move towards is care that is patient centered and, and I think um it gets back to that honest conversation. What is important to the patient, what is important to you is the healthcare provider. The important thing is that I have a honest conversation and these can be difficult about the important bits and the most important bits are what we do to patient's in life, not what we do to them once their heart stopped. Uh If we focus on that, I think we will deliver better care for our patient's. And I would argue a more satisfying experience for healthcare providers as well. I'm very sorry. I can be with you today to take questions, but I hope uh you enjoyed the presentation. Thank you again.