Further to my post NSW advance care directives and paramedics (August 30, 2020) I received the following from someone in the Non-Emergency Patient Transport (NEPT) sector.

I’ve been questioning our current protocol … regarding Advanced Care Directives, specifically the NSW Health documents that accompany patients who either have terminal conditions or are in palliative care. This is a fairly common transport, and we require a copy of these documents to accompany the patient in case of deterioration within our care. About 2 years ago, I noticed that while we were being given a copy of the front page, we were rarely, if ever, given a copy of the back. When we were, it was either not filled in, not signed by the AMO or not completed. The bottom of the document clearly states that both front and back pages need to be signed, but I would also argue that the information needs to be complete on the back of the form. Especially the information regarding the validity of the form, and the capacity of the patient to make these end-of-life decisions, and who (if not the patient themselves) has made this decision for them. I have become very insistent that nursing staff contact the treating team to complete these documents as it’s my understanding that;

1.         As the provider taking over the duty of care (and an AHPRA registered health care professional) of this patient, I would be legally responsible if, for whatever reason, this patient passes away in the back of the ambulance, I do not attempt resuscitation and either the family or the doctor had revoked this Advanced Care Plan or decided not to go ahead with it, thus the reason for it not being completed, making them for full resus.

2.         Without a date it expires, or time until which the document remains valid, being declared the appropriate section of the form the document is invalid.

3.         Especially in regards to patients with advanced dementia (being the reason for their “Not For Resuscitation” status) who are incapable of making these decisions for themselves, finding numerous resus plans with “Withholding resuscitation complies with the patients verbally confirmed wishes” is alarming, and such statement could potentially invalidate the document as well.

A link to a sample of the form is here. My employer has told me that as long as the nursing staff hands over that there’s an NFR order, and the front page of the document exists and is signed, that’s good enough. However, I don’t believe this is based on legal advice, and I’m concerned that following this would leave me open to risk. The private industry in NSW Patient Transport is rapidly changing and keeping up legally as a staff member is hard.

Hope this question makes sense as I’ve tried to understand it myself and this is as far as I’ve gotten.

I note that patient transport officers are not registered under the Health Practitioner Regulation National Law so I infer my correspondent is a ‘nurse, registered nurse, nurse practitioner, enrolled nurse’ or a paramedic (or a member of one of the other health professions), but nothing turns on that.

In answering this question I’ve also located a NSW health training slideshow that includes the form (see slide 6). The form does say (emphasis in original) ‘Complete and sign both front and back pages. A copy must accompany the patient on all transfers & be included in discharge summary.’

The starting point is that there is no legislation governing advance directives or resuscitation plans in NSW. The law is the common law that says that a patient can refuse consent to treatment even where that will shorten their life, and that health professionals are not under a duty to provide futile treatment. That means that a patient may be ‘not for resuscitation’ because the patient (or their substitute decision maker) has decided they don’t want that care or where the doctors have determined that such treatment is not in the patient’s best interests or is otherwise futile.  We can see that reasoning in the section ‘Rationale for withholding CPR’ (on page 2).

To turn to my correspondent’s assertions, we are all legally responsible for our decisions. The patient transport officer is ‘legally responsible’ for their decision to commence or withhold CPR in all the circumstances. There is no automatic obligation to resuscitate everyone unless this form is fully completed; the obligation is always to treat the patient in accordance with the patient’s best interests.  What that means is this form is not the ‘be all and end all’ – “if form completed, no CPR; if form not completed full resuscitation”. The form is simply one way to communicate the outcome of the medical decision making. The same information could be communicated orally, or in a letter. The advantage of the form is that it is consistent and unambiguous. The question should become whether the patient transport officer has any serious doubt about the situation. 

It would certainly be a concern if the document does not say how long it is valid for depending on when it was signed. If it was signed minutes before the patient was collected then one can infer it is intended to apply during the transport, but if it was executed a month ago one would have to question whether it was still intended to apply.

I would agree that there should be concern ‘in regards to patients with advanced dementia … who are incapable of making these decisions for themselves’ and the notation that ‘Withholding resuscitation complies with the patients verbally confirmed wishes’ as that implies whoever was completing the form was not giving it the attention it deserved.

Regardless of the form however, if the patient is receiving palliative care then by definition care is being provided to relieve symptoms rather than prolong life. If the patient is being transported to or from a palliative care setting one might be more confident that the ‘No CPR’ order is consistent with the treatment being given – see Withholding treatment from a patient in palliative care (November 19, 2019)). A patent with a ‘terminal condition’ may not be in palliative care, they may be expected to die of their condition but that may still be a long way off.

I think, given the absence of legislation, the issue is not whether every box has been completed but whether there is any reason to doubt the desires or medical opinion being communicated?  Whether one has cause to doubt that it is not intended to subject the patient to CPR depends on all the circumstances including what else is known about the patient’s history, conversations at the time of transfer etc.  If the patient transport officer is satisfied that there is an NFR order in place that is sufficient.  But, having said that, medical and nursing staff should recognise that these forms have been designed for a reason and that proper attention to detail would require both sides to be completed and it is prudent for anyone in the health team to insist, for everyone’s benefit, that the medical officer completing the form complete both sides. I commend my correspondent for becoming ‘very insistent that nursing staff contact the treating team to complete these documents’.

But insisting on ‘full resus’ just because page 2 has not been completed could not be either required or justified. One would have ot consider all the circumstances to make a call on whether there is any doubt about the intention that has been communicated by the details on page 1.

The fact that the document is included in the patient care file is a bit like Ms Shulman carrying her ‘no blood’ card in her wallet. If ‘the family or the doctor had revoked this Advanced Care Plan or decided not to go ahead with it’ or it was still being subject to discussion it should not yet form part of the medical record. The fact that it is included forms part of the evidence to guide decision making. If there is actual reason to doubt its veracity then yes that should be clarified ideally before transport commences.