10 / 10 / 2016
A nationwide campaign in Wales has sought to improve dialogue between patients and healthcare practitioners on the issue of do not attempt cardiopulmonary resuscitation (DNACPR) orders among patients with a terminal illness.
This case study is most relevant to:
- Acute trusts
- Ambulance trusts
- Foundation trusts
- NHS trusts
The challenge and the context
CPR is an emergency procedure with the aim of restarting the heart and breathing when they have ceased to function. Cardiac arrest is a medical emergency, but for many it is also a natural process at the end of life.
Talking about CPR is important when a patient has a palliative, terminal illness, and it is best to hold discussions when a person still feels reasonably well and can express an opinion on whether the intervention is something they would consider appropriate for themselves or not should it become necessary. This is where DNACPR (do not attempt cardiopulmonary resuscitation) discussions become important.
There is a need to explain CPR and its low success rate in people with advanced palliative illness better within society, and to create reproducible ways of giving clinicians opportunities to gain confidence in talking about this difficult topic. This represents prudent healthcare at its most forward planning, inclusive and judicious.
What was done
The ‘TalkCPR’ project in Wales was launched and aims to improve communication and dialogue between patients and their healthcare professionals with regard to do not attempt cardiopulmonary resuscitation (DNACPR) orders.
The venture represents a collaborative effort between all NHS Wales health boards and trusts, the Dying Matters in Wales charity, Byw Nawr, and support from the Bevan Commission as a Bevan exemplar project. It formed part of an NHS Wales IQT leadership project and required much creative collaborating with the Digital Legacy Association and the Welsh film production company Gingenious.
Initially, two videos (in English and Welsh) were produced for patients and carers who wanted to know more about this topic and wanted it as a resource to help shared decision-making with their clinical team.
Two further videos were developed to provide healthcare professionals with tips and approaches to start this difficult conversation. Provisions have also been made for blind, partially sighted and deaf patients.
The resources can be found on all Welsh NHS health board/trust intranet sites, HOWIS, on YouTube, and the main resource sites is English and Welsh.
Results and benefits
The impact of these videos on patients, nurses and doctors was measured through pre- and post-video surveys and a focus group session. Survey results showed a significant increase in the confidence of staff to openly discuss DNACPR with patients and carers after watching the videos.
The videos have been rolled out in each health board and trust in Wales. Three English trusts have asked whether they can use the videos in their own setting, and Pulse magazine has written a feature for GPs in the UK on this novel video and website approach.
A media campaign has made the TalkCPR project highly prominent in the public domain, with the actor Benedict Cumberbatch reading out a letter at Hay Festival mentioning the project and a Guardian article on cardiopulmonary resuscitation going viral.
Both NICE and the GMC have published the TalkCPR website resource.
The main obstacles were different IT structures across the health boards, so we had to create web and video formats that ran with old Internet Explorer versions. Computers that would not allow YouTube access and did not have loudspeakers, also featured as issues to overcome.
To circumvent this, we made the videos accessible in a variety of formats and adding subtitles, with the help of individual IT communications department leads. Two health boards stopped blocking YouTube as a result of our concerns that it restricted educational opportunities for staff.
It is hoped that the use of video and website information for patients around difficult areas such as CPR wishes can inform part of a more sharing approach, allowing patients and their proxy to be involved in key decisions and providing good quality information.
The TalkCPR website and videos are open source and available everywhere. Patients are increasingly using mobile smartphones, tablet computers and laptops at their bedside, and many have fed back on how useful they have found TalkCPR as a supplement to the discussions they had with their doctor or nurse.
We have created a social media campaign to promote this work and the hashtag is #TalkCPR
Want to find out more?
Get in touch with Dr Mark Taubert, consultant in palliative medicine, at Mark.Taubert@wales.nhs.uk