Background The ‘Sharing and Involving’ Clinical Policy for Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) for Adults in Wales sets standards for how DNACPR decisions are documented and shared. The aim was to find out if Ty Olwen, a 14 bed Inpatient Palliative Care Unit in South Wales, meets the specified standards.

Method In October 2016, a new DNACPR discharge checklist was created to improve practice and enable collection of prospective data for this audit. Data collection took place in December 2018, of all discharged between October 2016 and November 2018. Following an education intervention, the audit data collection was repeated in August 2019 for discharges between January 2019 and July 2019. Compliance with each standard was calculated as a percentage.

Results Between October 2016 and November 2018, 64 patients were discharged from Ty Olwen. There were 58 completed checklists during this period. 93% of DNACPR forms were signed or countersigned by a senior responsible clinician. 90% of patients were given a copy of the DNACPR form prior to discharge. 86% of DNACPR forms were forwarded to the patient‘s GP. The audit data and our recommendations were presented at the Ty Olwen clinical governance meeting. Re-audit in August 2019 showed limited improvement to these figures.

Conclusion Ty Olwen is not fully compliant with the policy standards. Other hospices and inpatient units in Wales, and across the UK, may face similar challenges. This audit, and the resulting recommendations, should be considered by palliative care teams throughout Wales to measure and improve compliance with the national policy.