APPENDIX 5
Children’s Centre
City Hospital Campus
Hucknall Road
Nottingham
NG5 1PB
Consultant:Dr Toni Wolff, Consultant Paediatrician
0115 962 7658 / 969 1169 Ext: 37902 – Stacey
Fax: 0115 962 7915
Email:
Draft Personal Resuscitation Plan for Child / Young Person
Created ______Amended ______
1.
Name:Hosp no:
DOB
Address:
- Background
Diagnosis/reason for plan
3.Resuscitation Plan
3.1.Acute deterioration
In the event of a sudden collapse with respiratory and or cardiac arrest:
Symptoms/signs to expectCarefully and clearly delete all options not needed and complete boxes as needed :
1. Comfort & support child and family
2. Suction upper airway
3. Increase O2 until looks comfortable
4. Face mask O2
5. Airway positioning
6. Oral airway
7. Naso-pharyngeal airway
8. Mouth to mouth / bag & mask ventilation - for mins
whilst heart beat/pulse
9. Endotracheal tube & ventilate
10. External cardiac compressions
11.Advanced life support including drugs and iv access
Name:Hosp no:
DOB
Address:
12. Transfer toe.g. Paediatric Emergency Dept / PICU
13. Who to call
if at home:
If at school:
If in respite:
If in hospital:
14. Other
15. Ambulance directiveyes/no
Name:Hosp no:
DOB
Address:
3.2.Slow deterioration
In the event of life threatening deterioration:
Symptoms/signs to expectCarefully and clearly delete all options not needed and complete boxes as needed :
1. Comfort & support child and family
2. Suction upper airway
3. Increase O2 until looks comfortable
4. Face mask O2
5. Oral antibiotics
6.iv access
- iv antibiotics
- other symptom relief:
Name:
Hosp no:
DOB
Address:
9. Transfer toPaediatric Emergency Dept / discuss with PICU or:
10. Who to call
if at home:
If at school:
If in respite:
If in hospital:
11. Other
Name:Hosp no:
DOB
Address:
4.Plan for review
The patient or parent / guardian can change their mind about any of these options at any time
day month year
5.The plan has been reviseddate
- The plan has been discussed with
Child or young person
Mother
Father
Guardian
Other people
Name:Hosp no:
DOB
Address:
7. Consultant’s agreement
I support this Personal Resuscitation Plan
Name & signaturedate
…………………………………………
8.Child or young person’s agreement
I have discussed and support this Personal Resuscitation Plan
Name & signaturedate
…………………………………………
9.Parent or Guardian’s agreement
I / We have discussed and support this Personal Resuscitation Plan
Name & signaturedate
…………………………………………
10.Team’s agreement
I / We have discussed this PRP with the child or young person / parent or guardian
Name & signaturedate
…………………………………………
Name:Hosp no:
DOB
Address:
11. Copies of this PRP are held by
Parents / guardian at home address and at
School contact details
Respite care contact details
Hospital contact details
Hospital (2) contact details
Ambulance Control contact details
(If applicable)
Local Notes contact details
(CDC or community)
Dr Wolff – Audit File contact details
C/o CDC
(with parents consent)
GP contact details
Name:Hosp no:
DOB
Address:
11. Copies of this PRP are held by (contd.)
Community Nurses contact details
Other contact details
Personal Resuscitation Plan for Child / Young Person
Background
This individual plan for resuscitation is to use instead of “DNR orders” as part of a child or young person’s palliative care, where they have a Life Limiting Condition or Life Threatening Condition (1). It can form one part of an agreed “End of Life Plan”.
The Personal Resuscitation Plan (PRP) may be most effective when drawn up by child / young person and their parents / guardian with a doctor who they know and who has known the child e.g. before they became so ill. This will not always be possible, but the PRP should not be the first thing mentioned when meeting the child / young person or family for the first time.
Circumstances will vary, from an intelligent, well, 14 year old with a diagnosed incurable life-limiting condition to a child in deep coma ventilated on PICU with a severe accidental traumatic brain injury. In all cases the child / young person’s parent or if possible both parents or legal guardian will be involved in drawing up the PRP. In some cases, e.g. at the suggestion of the doctor or nurse and at the discretion of the parent / legal guardian, the child / young person may also be involved; depending on conscious level, maturity, emotional state, capacity to understand, previously expressed wishes, options available.
This plan is flexible and is mainly to empower children / young persons and their families, to affirm what choice / control they have. It will help the child / young person’s and parents / guardian’s communication with medical, nursing and other professional services.
Completing the form
The blank form can be used to discuss options with families in a less threatening way than an discussion of “DNR” orders.
The form should be gone through with the child / young person and their parents / guardian as appropriate, by a senior member of the team, such as a community nurse or consultant paediatrician, items clearly deleted and boxes filled in as needed. A senior doctor (usually a consultant who knows the patient and family) will sign and date the form, either at the time or later. The child / young person and or parents / guardian can also sign but do not need to as they can over-ride this written plan at any time for any reason, i.e. they can change their minds and verbally ask for a different action e.g. more or less intervention.
As the plan can be changed at any time by the child / young person and parents / guardian there is no fixed review date, the form cannot “time –expire” any more than any other documentation of a discussion about therapeutic options in the patient’s notes.
The completed form can be photocopied (like any other page of the medical notes) for the family to have at home, for respite care etc.
Completing the form contd
Section 2 – Background
The reason why the child needs a resuscitation plan.
Put the diagnoses and brief description of the patient’s Life Limiting Condition or Life Threatening Condition in the box.
Sections 3.1 (Acute deterioration) and 3.2 (Slow deterioration) look similar; sometimes the resuscitation plan will be different for a sudden unexpected deterioration, which may be due to an intercurrent illness or event, compared to a more gradual decline, as anticipated by the patient’s diagnosis or underlying condition itself.
Put any anticipated circumstances in the boxes.
Carefully but clearly cross out all the options that are not wanted after discussion with the parents / guardian, and child / young person if appropriate. Use a firm black or blue pen, and make sure any corrections are clearly legible.
The same form can be used at home or in respite as in hospital, e.g. “mouth to mouth” in the community becomes “bag and mask” on the hospital ward. “Mouth to mouth” becomes “mouth to trachy” or “bag to trachy” for patients with a tracheostomy.
Fill in the boxes for options 3.1.13-15 and 3.2.9-11 to say where, if anywhere, the child should be transferred and who should be called, e.g. parent and bleep children’s community nurse if child is in respite or school, bleep community children’s nurse if child at home; or if in hospital the cardiac arrest/emergency medical support team – ensuring that they are made aware of the resuscitation plan.
It may be appropriate to call 999 paramedic ambulance if child is outside hospital with uncontrolled symptoms. In which case there needs to be a version of the resuscitation plan on EMAS headed paper and signed by their medical advisor to give to ambulance crew. (See additional notes). when child is in respite or school, key worker, or if in hospital “fast bleep” the SHO or SpR, call consultant etc.
Section 4 does not always need to be completed but a planned review may be agreed.
Date in Section 5 if this is a revised PRP, and send copies of revised PRP to all who currently hold a copy as in Section 11. Old versions should be crossed out with 2 bold single diagonal lines, on each page. Sign and date the crossing out.
If the child / young person has been involved in the discussions, usually with the parents / guardian’s support, they can sign Section 8, to acknowledge this, if they want, but do not have to. Similarly the parents / guardian do not have to sign section 9. The doctor or nurse or key worker who discussed the options with them, should sign and date section 10.
The child’s consultant must sign Section 7, even if the plan has been raised with the family by another senior member of the team.
Audit of patient and parents/guardian’s views
If appropriate ask how they felt about the discussions and completing the Personal Resuscitation Plan:
Please let us know how this was to discuss and complete
Mum Dad child(you)Mum Dad child
it made me feel betterI wish I had not
it was OK (neutral)I did not mind
it hurt (a little emotionally difficult)I am glad I did
it was very bad (emotionally difficult) people should not be asked
these questions
Dr Toni Wolff
Consultant Community Paediatrician with responsibility for paediatric palliative care, 0115.962 7658, Children’s Centre, City Hospital, NG5 1PB
Dr William Whitehouse
Senior Lecturer in Paediatric Neurology & honoury consultant paediatric neurologist, 0115.924 9924 ext 44476, E Floor East Block, QMC, NG7 2UH
17-02-06
Personal Resuscitation Plan for date – Page 1 of 12
Dr T Wolff – Version 1 (October 2006)