DNACPR: nurses’ step-by-step guide from Resuscitation Council UK

Expert advice to help you understand scope of DNACPR recommendations, capacity, and advance decisions to refuse treatment

Expert advice to help you understand scope of DNACPR recommendations, capacity, and advance decisions to refuse treatment

Nurse completes a DNACPR in consultation with a patient
Picture: iStock

Resuscitation Council UK ReSPECT (Recommended summary plan for emergency care and treatment) clinical lead Catherine Baldock and legal adviser for the ReSPECT process Alex Ruck Keene KC (Hon) answer some of the questions most commonly asked about do not attempt cardiopulmonary resuscitation (DNACPR) recommendations.

More about the ReSPECT process

What is the purpose of a DNACPR recommendation?

A DNACPR recommendation provides immediate guidance to healthcare professionals on the best course of action, should the person experience cardiac arrest or die suddenly.

Terminology: how should we talk about DNACPR?

A decision to recommend that cardiopulmonary resuscitation (CPR) is not attempted should be called a recommendation. To call them ‘DNACPR notices’ or ‘DNACPR orders’ implies a recommendation about future CPR is inflexible and will be followed, regardless of the circumstances at the time of the emergency.

A DNACPR recommendation is only that, whether contained in a stand-alone DNACPR form, or contained in a broader advance care plan or emergency care and treatment plan. A DNACPR recommendation serves the sole, important function of informing clinical decision-making at the time of the emergency.

Is a DNACPR recommendation legally binding?

No it is not. A DNACPR recommendation is a guide for clinicians who are responding to the emergency and have to make a decision about whether to start CPR.

Should a patient be involved in the conversation about DNACPR if they have capacity?

A patient who has capacity must be involved in DNACPR discussions
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Yes. If a patient has capacity, the courts in England and Wales [Tracey case (R (Tracey) v Cambridge University Hospitals NHS Foundation Trust & Ors [2014] EWCA Civ 822] have made it clear the individual must be involved in a conversation about CPR – unless to do so is likely to cause them to suffer physical or psychological harm.

It is important to understand a decision on whether or not to make a DNACPR recommendation is ultimately a clinical one, rather than one for the patient.

If the patient wishes to refuse CPR, they should be supported to make an advance decision to refuse treatment (ADRT).

Clinicians must be clear in their conversation with the patient why they think CPR should not be recommended. It could be because they think it would be futile, as it would not work; or it could be because they think CPR would not be in the patient’s best interests.

In either case, the patient can ask for a second opinion, but the clinical team does not have to obtain a second opinion if the decision that CPR would be futile was reached on a robust, multidisciplinary basis.

Advance decisions to refuse treatment

What is the difference between a DNACPR recommendation and an advance decision to refuse treatment (ADRT)?

An ADRT, as defined in the Mental Capacity Act 2005 in England and Wales, is a document that a person over 18 has drawn up when they had the capacity to do so, where they stipulate certain treatments they would not wish to receive, and the circumstances in which those decisions would apply.

There is no specific format for an ADRT, but an ADRT in relation to refusal of life-sustaining treatment must be given in writing, witnessed, and make clear it applies even if life is at risk. A clinician who attempts CPR in full knowledge of the valid ADRT would be both criminally and civilly liable.

If a patient has a DNACPR recommendation recorded on a form and goes into cardiac arrest – but that DNACPR form is not immediately available – should CPR be started?

If a patient is known to have a DNACPR recommendation, it is appropriate not to perform CPR, providing the clinician is confident the recommendation is still applicable and pertinent to the patient they are dealing with. The clinician at that point can have a reasonable belief that they are acting in the patient’s best interests.

If the patient goes into cardiac arrest and does not have a DNACPR recommendation, should CPR be started?

The default position is that steps should be taken to support life, so if the clinician considers that CPR is likely to be effective, they should start CPR.

The clinician is under no obligation to start CPR if they do not think it is likely to be effective in restarting the heart. If the clinician believes CPR will be effective, but they have information to form a reasonable belief that CPR is not in the person’s best interests, then CPR does not need to be performed.

An example in which the clinician would have such a belief is where a family member explains that the person has made clear that they would not want CPR, and the clinician has no reason to doubt the good faith of this explanation.

Hands placed on the sternum for chest compressions during CPR
Picture: iStock

If a patient has a DNACPR recommendation and starts choking, which leads to a cardiac arrest, should CPR be performed?

Yes, CPR should be performed because choking is a potentially reversible cause and performing CPR may dislodge/relieve the obstruction. A DNACPR recommendation should not affect the overall care and treatment a patient receives.

Should a recommendation about CPR be discussed as part of other emergency care and treatment?

Yes, CPR recommendations should be discussed with the patient as part of a conversation about their overall goals of care and treatment. This ensures the recommendation about CPR is put in context. Recommendations about DNACPR should not be made in isolation for two reasons:

  1. There would be too much focus on CPR at the expense of other goals.
  2. It risks giving the message that a person with a DNACPR recommendation would not want any other form of treatment escalation, which is entirely incorrect.

If a patient lacks capacity to participate in a conversation about CPR, who should be consulted?

If a person lacks capacity to participate, then any attorney for health and welfare or health and welfare deputy should be involved, as well as their family and those close to them, to understand what is important to the person.

The only exception is where it is impractical to do so. However, there is a high threshold clinicians must satisfy to be able to say that this is the case.

It is important to understand that none of these consulted parties can refuse or demand CPR on the person’s behalf. The making of a CPR recommendation is ultimately a clinical decision, informed by the views of those interested in the person’s welfare, rather than a decision of those people.

What if a person lacks capacity to participate in a conversation and has no family or anyone close to them?

If the decision-making is taking place in hospital they should arrange for an independent mental capacity advocate (IMCA) to be involved. However, the duty to arrange for an IMCA does not apply in a setting where they are not being cared for or treated by an NHS body.

However, in either case, where the person is unbefriended, medical professionals need to be astute to try to identify all relevant evidence for what the person would wish.

Do the same principles apply to those under 18?

The concept of mental capacity only applies to those over 16. Below age 16, the question is whether the child is Gillick-competent to participate in the decision-making process.

The most important consultation, if the child lacks capacity/competence should be with the person with parental responsibility, even though that person does not have the ability to consent to or refuse the making of the recommendation.

A person under 18 cannot make an ADTR, but they can express wishes and feelings, which should be taken into account in determining what course of action is in their best interests.