Following an incident it was flagged that advice to discuss ‘goals of care’ with a patient did not occur. The patient's condition deteriorated and they were readmitted a few weeks later.

Despite it being documented it would be too traumatic and was likely to cause injury, due to the lack of a DNACPR decision, CPR was performed. The patient later died as a result of acute illness on top of multiple co-morbidities which had been highlighted before. 

The family were unaware that the patient was at the end of life. So for them, the death of their relative was sudden and unexplained. Had they been expecting it, they would have stayed at the bedside and the patient experience, whilst sad, would have been the best it could be in the circumstances.

Our learning:

It's important patients are made aware of a DNACPR decision, made medically, when CPR won’t work, such as frailty or an advanced irreversible illness so conversations can take place as early as possible in their illness.

If that conversation cannot take place, colleagues should document:

• The clinical DNACPR decision without delay
• The reasons why the conversation can’t take place

The only acceptable reasons for not having that conversation are:

• high risk of causing psychological or physical harm
• the patient has capacity but refuses to discuss it
• the patient does not have capacity and reasonable efforts to contact those close to the patient have failed