Making a DNACPR decision

A DNA CPR decision should be made following careful consideration of the patients clinical
situation by the multidisciplinary team. The decision should be based on the benefits, burdens and
risks of undertaking CPR , and there shouldbe consensus that any attempt to restore the patients
circulation and/or breathing would not be in that persons best interests (GMC 2010). To aid the
decision making, Bass (2011) suggested asking the question: Does this patient present as a person
for whom arrest would be unexpected and sudden, and for whom the medical teamis as certain as
they can be that CPR would be successful? If the answer is no, then a DNA CPR decision should
be considered. The Gold Standards Framework (GSF) (2011) contains specific clinical indicators
of advanced disease that may also support decision making. To achieve successful end of life care
it is essential to identify and assess patients proactively. This includes regular monitoring of the
patients condition to ascertain whether CPR is likely to be in the patients interests. Following
identification of those in the last year of life, it is recommended that the patient should be added
to the supportive care register (GSF 2009), co-ordinated by the GP practice, in addition to an
electronic palliative care coordination system (National End of Life Care Programme 2010), both
of which aim to share information between service providers regarding end of life care preferences
and plans for care as appropriate. If the patient is in a care home, hospice or hospital, an additional
register specific to the organisation may be in use and therefore it is important to put in place
mechanisms that ensure all registers remain up to date. Once added to the register, it is
recommended that patients are coded according to whether they are considered to be in the last
months (green), last weeks (yellow) or last days (red) of life (GSF 2011). Identification and coding
of these patients enables the multidisciplinary team, in conjunction with patients and their relatives
and carers, to plan a head and review regularly their specific needs. This would include whether
or not undertaking CPR would be in the patients best interests.

Challenges associated with decision making

Decision making in relation to CPR can be complex and challenging. Most clinical models
discussing ethical dilemmas refer to four ethical principles (Beauchamp and Childress 2001):
Autonomy allowing people as much control over their lives as possible. Beneficence doing
good. Non-malificence not doing harm. Justice actions that are fair to those involved. In
relation to CPR , the multidisciplinary team needs to determine whether a DNA CPR decision is
required by asking the questions underpinning the ethical principles identified in Box 4. The BMA
, Resuscitation Council (UK) and RCN (2007) have provided a decision-making framework for
CPR

Implementing a DNACPR decision

Before implementing a DNA CPR decision, it is necessary to refer to the organisations (primary
care trust, care home, hospital or
hospice) DNA CPR policy. Once it is determined that CPR would not be in the patients best
interests, the most senior medical clinician overseeing the patients care has overall responsibility
for discussing the decision with the multidisciplinary team and communicating this to social care
providers, relatives and the patient where appropriate (BMA et al 2007). Although a DNA CPR
decision is ultimately a clinical decision, early discussion with the patient is recommended unless
it is considered that having such a discussion would cause more harm than good because of the
distress it might cause (GMC 2010). In the hospital setting, the senior clinician is likely to be the
patients consultant, and in the community setting it is likely to be the GP. The decision must then
be documented, stating clearly that CPR should not be attempted in the event of a cardiopulmonary
arrest expected as part of the dying process. The process for arranging a DNA CPR decision is
outlined in Box 5.

Patient and relative considerations

Conversations with patients who are at the end of life can be emotionally demanding and
challenging (Lugton and McIntyre 2005). Practitioners maybe reluctant to engage in such
conversations because they are fearful of causing distress and affecting their therapeutic
relationship with patients. However, when undertaken sensitively,such conversations can have a
positive effect on patients and carers by showing that practitioners are approachable, respectful
and honest (DH 2000, Wilkinson et al 2008). The GMC (2010) states that it is a requirement to
carefully consider whether it is necessary or appropriate to tell the patient that a DNA CPR
decision has been made, and recommends that you should not make assumptions about a
patients wishes, but should explore in a sensitive way how willing they might be to know about a
DNA CPR decision. By not discussing the decision, if the patient and/or family unwittingly read
DNA CPR documentation held in the patients records, questions regarding withholding of
treatment could be raised. Johnson and Nelson (2008) suggested that the choice of whether to
discuss DNA CPR decisions must be made after considering Beauchamp and Childress (2001)
ethical principles, identified earlier in this article (Box 6). Confidentiality is another important
issue to consider when initiating a DNA CPR discussion (Nursing and Midwifery Council 2008).
It is essential at the outset that permission is gained from the patient to share information with
family members. A family member may instigate CPR and involve emergency services if the
cardiorespiratory arrest occurs outside the hospital setting and if he or she is not aware that a DNA
CPR decision was in place. If a DNA CPR decision is in place, families and carers would need to
know the appropriate care providers to alert when their loved one dies, how to contact them and
what interventions these healthcare professionals are able to undertake.

What happens if the patient or family disagree with a DNACPR decision?

The guidelines produced by the BMA , Resuscitation Council (UK) and RCN (2007) state that
patients can only refuse treatment and cannot request any medical interventions, including CPR .
In such situations, the GMC (2010) recommends that an effort is made to understand the patient
and/or familys perspectives, ideas and expectations, which may be based on unfounded
assumptions or lack of information. As previously mentioned in Box 4, the GMC (2010) also
recommends that in situations where there is dispute regarding a DNA CPR decision, in an effort
to achieve consensus it may be worth considering involving an independent mental capacity
advocate, seeking advice from more experienced colleagues, obtaining a second opinion, holding
a case conference, or using local mediation services. In the event that consensus is not reached and
the patient or family insist that CPR is undertaken in the event of cardiorespiratory arrest, the GMC
(2010) recommends that if the benefits and potential risks are closely balanced, the patients or
familys choice may be the deciding factor. However, the GMC (2010) also states that the clinician
is not obliged to agree to attempt CPR when cardiopulmonary arrest is expected as part of the
dying process and the aim is to achieve a peaceful, natural death.

How do people react to DNACPR discussions?

Peoples reaction to DNA CPR discussions varies. Johnson and Nelson (2008) found that DNA
CPR discussions can encourage patients and their families to discuss end of life care, and
potentially provide reassurance that inappropriate and potentially distressing interventions that are
not in the patients best interests will not be performed. However, some people may view CPR as
a genuine option to prolong life, or if a patient is using non-acceptance as a coping strategy
discussions about DNA CPR decisions could impinge on the patients psychological wellbeing.

Are there occasions when a DNACPR decision would not be valid?

A DNA CPR decision does not override clinical judgement if the reason for the cardiorespiratory
arrest is not associated with the patients underlying condition, for example if the arrest happens
under anaesthesia during surgery (GMC 2010).

Is the nurse required to perform CPR if a patient at the end of life experiences a
cardiorespiratory arrest without a DNACPR decision?
If a DNA CPR decision has not been made or is unknown, a healthcare worker might feel obliged
to perform CPR when a patient collapses. In these circumstances, the GMC (2010) states that
CPR should be attempted unless you are certain you have sufficient information about the
patient to judge that it will not be successful. This highlights the importance of ensuring that
patients are reviewed regularly, and that the appropriateness of interventions such as CPR are
discussed and communicated with the multidisciplinary team and the patient or family were
appropriate (Box 7).

Can a patient at the end of life make a decision not to be resuscitated?

Some patients may want to make their wishes clear in advance regarding medical treatments that
they do not want provided. It is important to remember that if a patient lacks capacity and
information about an advance refusal of treatment has been verbalised or documented, valid and
applicable advance refusals must be respected (GMC 2010). The GMC also states that if a patient
lacks capacity the healthcare professional should inform any legal proxy and others close to the
patient about the potential DNA CPR decision (GMC 2010). Each country in the UK has its own
distinct legal framework regarding advance decisions to refuse treatment. In England, Wales and
Scotland, legislation enables patients (over 18 years in England and Wales, and over 16 years in
Scotland) to refuse medical treatment in advance, including CPR , provided they are deemed to
have the mental capacity to make this decision
(Scottish Government 2000, Office of the Public Guardian 2007). In England and Wales, this
decision is legally binding, so long as the advance refusal is clearly applicable to the patients
present circumstances (GMC 2010). Guidance regarding advance decisions to refuse treatment has
been produced by the NHS End of Life Care Programme and the National Council for Palliative
Care (2008). In Scotland, advance decisions to refuse treatment are not legally binding, however
a patients wishes would be taken into account by those making decisions on his or her behalf
(Scottish Government 2000). In Northern Ireland, there is no legislation surrounding mental
capacity, but it is likely that the principles established in English case law precedents would be
followed (GMC 2010). Practitioners have a professional responsibility to be familiar with
legislation in their country of practice. At present there is no requirement for a patient to involve
a healthcare professional when making an advance decision. However, patients may disadvantage
themselves if they have not discussed these issues with a healthcare professional. For example, a
patient with chronic obstructive pulmonary disease may refuse intravenous antibiotics in advance
in the event that he or she acquires a chest infection. However, he or she may not be aware that
this intervention may potentially reduce distress at the end of life. If patients make advance
decisions, then it is their responsibility to let the healthcare team know although they may need
assistance to identify who they should inform. If the patient has made an advance decision not to
be resuscitated in the event of cardiopulmonary arrest even if his or her life is at risk, theoretically,
a DNA CPR decision should not be required as the decision has already been made by the patient
(Box 8). A record of who has been informed of this decision will then need to be made, and if the
advance decision is later
withdrawn, this would also need to be circulated to the same parties. It is important to note that in
England, Wales and Scotland, an advance decision would no longer be valid if the patient had
appointed a lasting power of attorney for health and welfare (England and Wales), welfare power
of attorney (Scotland), and enduring power of attorney (Northern Ireland, NI Direct Government
Services 2012) after the advance decision was made (Scottish Government 2000, Office of the
Public Guardian 2007), since the lasting power of attorney would now be responsible for refusing
treatment based on what he or she thinks the patient would have wanted at the time. Further
information regarding advance decisions to refuse treatment is available (NHS) End of Life Care
Programme and the National Council for Palliative Care 2008, Macmillan 2012).