1. DO NOT ATTEMPT RESUSCITATION (DNACPR)
Diane Hughes
Resuscitation Training Manager

2. Aim:
To introduce the Trust’s DNACPR Policy and to raise awareness of the legal and ethical issues surrounding DNACPR decisions

3. Objectives:
To be aware of the DNACPR Policy and the reasoning behind it
Understand the legal issues
Understand responsibilities
To be fully aware of correct documentation

4. Policy To Assist staff in planning of patient care & decision making
Clarify the process surrounding the making of an advance DNACPR order in a range of settings
Identify key ethical & legal issues underpinning decisions
Decision in one case may be inappropriate in an apparently superficially similar case
Individual circumstances are important

5. Scope of the Policy
This Policy relates only to those interventions required when an individual suffers a respiratory and/or cardiac arrest, i.e. CPR
All other treatments, interventions and general nursing care which are appropriate to the individual, are not precluded and should not be influenced by the DNACPR order
A DNACPR is different and separate to an Advanced Decision, but they may run alongside one another

6. Why Policies are Needed
Joint Statement from BMA Resuscitation Council (UK) & Royal College Nursing (Feb 2001)
Before this statement, Trusts were not obliged to have a policy on DNACPR
Issued guidelines for establishments facing decisions about attempting resuscitation
These guidelines outline situations where decisions are made in advance and form part of patient care plan
Emergency situations where no advance decision has been made are also covered
Trust Policy is based wholly on this guidance and with reference to the Human Rights Act 1998 and the Mental Capacity Act 2005

7. Why Policies are Needed
Cardiopulmonary Resuscitation (CPR) can be attempted on any person whose cardiac or respiratory functions cease
Failure of functions are inevitable as a part of dying and thus CPR theoretically could be attempted on every individual prior to death
For every person there comes a time when death is inevitable, therefore it is essential to identify patients for whom cardiopulmonary arrest represents a terminal event, so making CPR inappropriate
It is essential to identify those patients who do not wish CPR to be attempted and who competently refuse it

8. Human Rights
The Human Rights Act 1998 aims to promote human dignity and clear decision making
Provisions relevant to CPR include:
Article 1 The right to life
Article 3 The right to be free of Inhuman or degrading treatment
Article 8 The right to respect for privacy and family life
Article 10 The right to freedom of expression, including the right to hold opinions and receive information
Article 14 The right to be free from discriminatory practice

9. Responsibilities
Overall decision and responsibility rests with Consultant or GP in charge of patient’s care
Decision must be reached after discussion with patient, people close to patient (where appropriate and unless specified otherwise by competent patient) and multi-disciplinary healthcare team
Consultant or GP takes overall responsibility for ensuring that decision is recorded appropriately and is conveyed to all involved in patient’s care
The Doctor may delegate this responsibility to other medical staff or Senior Nurse if appropriate

10. Nurse’s Responsibilities
Senior nurse is responsible for ensuring that all ward staff and community colleagues involved are aware of the DNAR order
Where a patient is transferred from another hospital or community setting with a DNACPR order in place, Senior nurse should discuss with consultant or GP to ensure the decision is reviewed by new Consultant/GP within 5 days maximum
When using ambulance service to transfer patient, Ambulance Control MUST be informed of DNACPR when ordering transport
Ambulance service require written, signed information from consultant/GP indicating order in place as well as written consent from patient
Written information should be in patient’s notes whilst in hospital & given to ambulance personnel when patient transferred.

11. Nurse’s Responsibility cont.
Senior Nurse must ensure team receive mandatory training in both Basic Life Support (annually) and DNACPR decisions (on appointment, after any significant policy change or as required, for all inpatient staff only)
Senior Nurse must work closely with consultant or GP on all issues relating to cardiopulmonary resuscitation issues, including overseeing correct documentation
REMEMBER, a DNACPR order is fully consistent with patient also receiving maximum therapeutic medical/nursing interventions

12. Legal Issues
Competent adults have the right to refuse medical treatment even if refusal results in death
Refusal of treatment by competent young people is not necessarily binding upon doctors, but it may be advisable/necessary to seek legal advice
Those with “parental responsibility” are generally entitled to give consent on behalf of their children
N.B. Not all parents automatically hold “parental responsibility”. If in doubt, CHECK

13. Legal Issues cont.
The views of people close to incapacitated adults should be considered as they often feel excluded, though it must be clear that their views have no legal status, unless previously agreed under the Capacity Act provisions
If patient has competency, their agreement should be sought before involving relatives in decision making – Refusal by a competent patient to allow information to be disclosed to family/friends must be respected
Where there is disagreement between the views of the Doctor and the patient, legal advice should be sought

14. Where No Advance Order
For the majority of patients, the risk of cardiopulmonary arrest is small and so no advance decision is usually made
In these situations and where the opinion of the patient is unknown, every attempt to revive patient should be made – includes emergency situation
There is no ethical or legal requirement to discuss every eventuality with all patients

15. Situations when DNACPR order may be appropriate
Where attempting CPR will not restart the patient’s heart and breathing (decision must be based on clinical assessment of condition)
Where there is no benefit in restarting the patient’s heart and breathing (if only brief extension to life, patient will never have awareness, or are likely to suffer severe unmanageable pain)

16. Situations when DNACPR order may be appropriate, cont’d
Where the expected benefit is outweighed by the burdens (Courts ruled it is lawful to withhold CPR on the basis it will not benefit the patient – decision reached after consideration of relevant medical factors and whether treatment may provide a reasonable quality of life)
Where CPR is not in accord with the patient’s wishes (CPR must not be attempted if contrary to patient’s sustained and recorded wishes – this does not have to be in writing, if expressly detailed to those involved in patient’s care
Where previously discussed with GP/consultant and recorded in notes, refusal is likely to have the same status as an Advance Decision

17. Terminally Ill people
The issues should be explored sensitively with patient
Both the likelihood of success and the expected resulting quality of life are appropriate issues for discussion.
Although the raising of such issues may be distressing, it is good practice to make decisions based on clinical condition of patient and their wishes
It is essential to identify patient’s for whom a cardiopulmonary arrest represents an inevitable terminal event in their illness and in whom CPR is inappropriate
In the absence of an anticipatory DNACPR or a valid Advance Decision, at the time of cardiopulmonary arrest, the patient is by definition incompetent, so it is therefore the Doctor’s legal responsibility to act in “the patient’s best interests”

18. Patient’s Refusal Of DNACPR Order
This may arise when a terminally ill patient requests that “heroic measures” be taken even if clinical evidence suggests that it will not be effective or provide any benefit to the patient
Following sensitive discussions, if the patient persists in their view, this should be respected
Subsequently if patient’s condition improves and CPR becomes a practical option, this should be discussed with patient and all reasonable efforts to revive patient should be made

19. Recording DNACPR Decisions
A DNAR is a very important decision and will decide whether or not attempts are made to resuscitate a person.
Therefore, it is vital that it is documented correctly and fully.
ALL DNACPR’s must be documented on RiO – not the old paper forms
If it is not endorsed by the senior clinician (usually the Consultant) or has gone beyond it’s review date- then it is NOT valid

20. Recording DNACPR Decisions on RiO
From the bed screen, in the appropriate patient’s section, click on Inpatient Forms
This screen shows whether a DNAR has been completed or not

21. Click on Inpatient folder – the menu on the right will appear
Click on Do Not Attempt Resuscitation (DNACPR) Proforma – the screen below will appear
If a DNACPR is already in place, the date it was documented will appear, click on this to view and/or edit
If no DNACPR yet in place, it will say this and at the bottom of the screen will be a ‘create new’ box – click this to begin documenting

22. DNACPR Proforma
Patient’s details will be automatically imported – check that they are correct before progressing

23. These questions contain yes/no radio buttons – ALL must be completed
You must check whether the Power of Attorney is for Welfare or Finances – a Finance Attorney would have no jurisdiction over this decision

24. It is important that these sections are completed fully with as much detail as possible – they are free text boxes and will expand as required

25. ALL staff involved must also be completed – not just the most senior
Communication must be fully completed, including names and relationships to avoid any confusion.
ALL staff involved must also be completed – not just the most senior

26. The DNACPR documentation can be entered onto RiO by any clinician, but it must be endorsed by the Consultant at the earliest possible opportunity, otherwise it will not be live and valid
If the endorsement is not completed, it will not be considered active and so will not be pulled through to the bed screen
You will NOT be able to save the form until a valid review date is entered

27. Review Of Decisions All DNACPR decisions must be reviewed regularly
Frequency of review to be agreed by Doctor and Senior Nurse involved
Standard review period 28 days
Exceptions may be made in patients for example with dementia, where improvement does not exist and deterioration is inevitable. The review period may then be extended up to a maximum of 3 months

28. Review of Decisions cont.
Review process should consider:
Change in patient’s condition
Change in patient’s wishes
Patient’s ability to participate in decision making as this may fluctuate
All reviews must be recorded on the DNACPR Proforma in RiO and a new review date set and details of the review documented in the patient’s progress notes

29. Advance Decisions (AD)
Must be made when a person has capacity- it is a decision to refuse specific treatment and is legally binding
If treatment being refused is life sustaining, such as CPR, it must be in writing and witnessed
A person has the right at any time whilst they retain capacity, to revoke this AD.
If a person no longer has capacity, but has a Lasting Power of Attorney (LPA) under the MCA 2005, the LPA will have the right to revoke the AD so long as they were appointed after the AD was made

30. Advance Decisions (AD) cont’d.
Even if informed by relatives that an AD exists, healthcare staff are not bound to comply with it unless they are satisfied of it’s existence and validity, and must insist on seeing it
If there is insufficient time for the document to be produced, e.g. in emergency situation, the medical team must decide what is in the patient’s best interests

31. Information for Patients
Written information should be given to patients
Information should convey that for most patients question of resuscitation may not arise
The BMA, RC(UK) and RCN leaflet entitled “Decisions Relating to Cardiopulmonary Resuscitation” should be made available as guidance to patients/carers
This leaflet can be downloaded from the BMA website
Time must be set aside for any patient requesting discussion of the issues