- Discuss resuscitation decisions with the patient or with relatives and carers.
- Draw up a management plan and try to resolve disagreements in advance.
- Document the reasons for a DNACPR order.
- Take account of relevant guidance and your local DNACPR policy.
The purpose of DNACPR orders
In the right circumstances, a Do Not Attempt Cardio-pulmonary Resuscitation (DNACPR) order helps ensure that a patient's death is dignified and peaceful. It should be considered when:
- a dying patient is at foreseeable risk of cardiac and respiratory arrest and CPR is not clinically appropriate
- the risks and uncertain outcome of CPR could outweigh any potential benefits
- a patient with capacity has expressed a clear wish not to be given CPR.
Hospital trusts are legally obliged to have a clear DNACPR policy for staff to follow. It must be accessible so that patients and/or their families are able to understand the decision-making process.
Good practice for healthcare professionals is set out in the GMC's end-of-life care guidance, and joint guidance from the Resuscitation Council, BMA and RCN. The Scottish Government has produced its own online DNACPR policy and resources.
Making DNACPR decisions: principles
The DNACPR decision-making process should take account of the benefits, risks and burdens of CPR and consider the patient's wishes and preferences, the views of the healthcare team and, when appropriate, those close to the patient.
If you are involved in providing end-of-life care, there are some principles to bear in mind.
- Be familiar with your local policies and procedures, good practice guidance and the law.
- Plan ahead as much as possible. Anticipatory decision-making will minimise delays and help ensure the patient's wishes and preferences can be taken into account.
- Do not make assumptions about their quality of life, age, or level of disability. A DNACPR decision should be specific to the individual patient's needs and wishes.
- The Appeal Court has ruled there should be a presumption in favour of involving patients or those close to them in the decision-making process. Barriers such as time of day or concerns about causing distress are not necessarily a reason to avoid a discussion.
- Discussion with patients should not be avoided unless you believe it would cause them physical or psychological harm. Document a decision not to involve the patient and your reasons for it.
- Approach the subject of CPR sensitively, as part of a wider discussion about the patient's wishes concerning care and treatment. Where possible, the Resuscitation Council recommends this is done in the patient's home setting, involving a healthcare professional who knows them well, such as their GP.
- As part of the discussion, explain the burdens and risk of CPR interventions, including the likely clinical and other outcomes if CPR is successful and any doubts that you and the healthcare team have about whether the burdens and risks of CPR would outweigh the benefits.
- Respect the wishes of patients if they tell you they do not want to know details about their condition or treatment but make it clear that they can change their mind at any time. Document the discussion. Seek the patient's consent to share information with those close to them to support their continued treatment and care.
Adult patients without capacity
- Find out whether the patient has previously made a valid advance decision to refuse treatment or whether a representative has legal authority to make decisions on their behalf, eg lasting power of attorney or independent mental capacity advocate (IMCA).
- If no legal proxy exists, the senior doctor is responsible for deciding which treatment will provide overall benefit. This should take into account anything known about the patient's wishes, feelings, beliefs and values; the views of those close to the patient, and of the healthcare team.
- Sensitively discuss the nature of CPR, its risks and chances of success with those close to the patient and anyone who has been made a proxy decision maker on the part of the patient, for example family members, or the holder of a relevant power of attorney.
- Where no proxy decision maker has been appointed, be clear to family members that their role is to advise you and the healthcare team about the patient. The GMC says that 'you must not give them the impression that it is their responsibility to decide whether CPR will be of overall benefit to the patient'.
- A CPR decision must be in the child's best interests, taking into account its risks, benefits and likelihood of success. Follow the steps set out in the GMC's guidance on treating children.
- Try to involve patients, their parents and the healthcare team in DNACPR decision-making. If the patient is Gillick competent, this should be with their consent.
It is sometimes difficult to decide whether the risks of CPR outweigh the potential benefits and occasionally patients or their family disagree about whether a DNACPR order is appropriate.
- If the benefits, burdens and risks of CPR are finely balanced, the patient's wishes will usually be the deciding factor.
- Where the overall benefit of CPR is in doubt but patients or their legal representatives want it to be attempted, ensure they are fully informed about the nature of treatment, its chances of success and the risks. Explore their wishes and try to reach agreement. If, after discussion, you still consider that CPR would not be clinically appropriate, you are not obliged to agree to attempt it. However, you should explain your reasons and their right to seek a second opinion or legal advice.
- Consider options such as a case conference or mediation to resolve disputes concerning children. Seek legal advice at the earliest opportunity if it is still not possible to reach agreement.
Recording DNACPR decisions
- Make a clear note in the patient's records about the DNACPR discussion and your reasons for recommending a DNACPR order. The joint guidance from the Resuscitation Council, BMA and RCN includes advice on good documentation.
- Ensure that DNACPR decisions are communicated to everyone involved in the patient's care, such as their GP, care home staff and the nursing team. Many NHS organisations have a standard local DNACPR form which can be stored with the patient's record and shared.
Ongoing care and review
You should continue to provide clinically appropriate care and treatment either with the consent of the patient or their legal representative, or if it is of overall benefit to them.
Review DNACPR orders to ensure they are still appropriate. This should be set out in your local policy and will usually include when there is a significant change in the patient's condition or at the request of the patient or their family.
If there is no time to make an assessment and no DNACPR order, you should attempt emergency CPR, unless you have enough information to judge it would be unsuccessful.
It is a good idea to seek assistance from the MDU if you are unsure about law surrounding CPR, or how to proceed in difficult circumstances.
This guidance was correct at publication 05/01/2017. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.