Expert advice

Why the current rules mean only a DNAR can offer certainty on resuscitation

Until the NMC clarifies its position on CPR, nurses and employers may face a practice dilemma, says Marc Cornock

Until the NMC clarifies its position on CPR, nurses and employers may face a practice dilemma

A person undertaking CPR on a patient
Picture: iStock

Earlier this week, it was reported that an experienced nurse who failed to administer cardiopulmonary resuscitation (CPR) to an 89-year-old care home resident had been suspended from the nursing register.

This is not the first time a nurse has faced sanctions from the Nursing and Midwifery Council (NMC) for failing to perform CPR on a care home resident.

In 2017, there were two separate cases of nurses in care homes being reprimanded by the NMC for not attempting to resuscitate residents.

When no DNAR notice is in place

In both cases, no Do Not Attempt Resuscitation (DNAR) notice was in place for the resident and the nurse thought the patient had died.

NMC conduct and competence committees subsequently found the fitness to practise of both nurses to be impaired by reason of misconduct and imposed a sanction on each nurse.

In reprimanding these two nurses, the NMC appeared to be saying that neither was competent to make decisions about whether the residents should receive CPR, and that resuscitation should have been attempted in both cases.

But this goes against best practice guidelines drawn up by the British Medical Association (BMA), the RCN and the Resuscitation Council (UK), which say ‘if there is no realistic prospect of a successful outcome, CPR should not be offered or attempted'.

The guidance also says ‘there will be cases where healthcare professionals discover patients with features of irreversible death, for example rigor mortis. In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies’.

‘Legally, only doctors can certify death; nurses and paramedics can verify death, but only if they have undergone appropriate training’

The NMC made reference to this guidance at the fitness to practise hearing of Nahid Nasiri, the nurse in the most recent case, who worked at Woodlands Nursing Home at the time of the incident on 6 August 2017.

There was also no DNAR notice in place in this case, and Ms Nasiri was aware of this.

Making a clinical decision about attempting CPR

At the coroner’s inquest and in her submission to the NMC during its investigation, she argued that her decision not to attempt CPR on the resident, who had stopped breathing, was ‘a carefully considered clinical decision’.

However, the NMC panel said it found no evidence that it was a carefully considered clinical decision. Any attempt to rely on the best practice guidelines from the BMA, RCN and Resuscitation Council (UK) in this case would therefore be futile, as the guidance requires the nurse to make a clinical decision about the prospects of successful CPR.

Although the facts of the three cases are different, the key to all of them is the lack of a DNAR notice and the fact that none of the nurses were qualified to verify death.

Legally, only doctors can certify death; nurses and paramedics can verify death, but only if they have undergone appropriate training.

A DNAR removes ambiguity for patients and nurses

All three cases show how vital it is that discussions about resuscitation status take place as early as possible where appropriate. If this had happened in these cases, and DNAR notices were put in place if that was what was decided, the nurses would not have found themselves facing sanctions from the NMC, as this would have justified the decision not to undertake resuscitation.

‘This is the only way a nurse can defend themselves against a charge that their fitness to practise was impaired by reason of misconduct, even if this means inappropriate treatment is given’

Alternatively, if it was decided that the resident was to be resuscitated in the event of a cardiac arrest, there would be no ambiguity and the nurses would have known exactly what was required of them.

These cases also highlight how important it is for care home nurses to undertake training to be able to verify death. As it stands, if you are not qualified to verify death and no DNAR notice is in place, it would appear, to avoid being brought before the NMC you have to start CPR, despite what the best practice guidance says.

Based on these cases and until the NMC clarifies its position, this is the only way a nurse can defend themselves against a charge that their fitness to practise was impaired by reason of misconduct, even if this means inappropriate treatment is given. 

If the family complains that your actions resulted in the resident not being treated with respect, your defence would be that you were following the expectation of your regulatory body, and that you had no choice.


Marc Cornock, qualified nurse, academic lawyer and senior lecturer at the Open UniversityMarc Cornock is a qualified nurse, academic lawyer and senior lecturer at the Open University. He gives his views in a personal capacity only and they do not reflect those of the RCN or RCNi

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