Expert advice

DNACPR notices: what nurses need to know

Nurses’ input can inform a decision about whether to perform cardiopulmonary resuscitation

Nurses input can inform a decision about whether to perform cardiopulmonary resuscitation

What is a DNACPR notice?

A do not attempt cardiopulmonary resuscitation (DNACPR) notice advises healthcare professionals not to attempt cardiopulmonary resuscitation (CPR) for a person. It is a document issued and signed by the most senior clinician in charge of the persons care, which is normally a doctor but can be a senior nurse.

The document can also be known as a DNAR (do not attempt resuscitation) notice.

Decisions only apply to CPR and all other appropriate treatment and care for that individual should continue, says joint guidance published by the British Medical Association (BMA), the Resuscitation Council UK (RCUK) and the

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Nurses’ input can inform a decision about whether to perform cardiopulmonary resuscitation

Picture: iStock

What is a DNACPR notice?

A do not attempt cardiopulmonary resuscitation (DNACPR) notice advises healthcare professionals not to attempt cardiopulmonary resuscitation (CPR) for a person. It is a document issued and signed by the most senior clinician in charge of the person’s care, which is normally a doctor but can be a senior nurse.

The document can also be known as a DNAR (do not attempt resuscitation) notice.

Decisions only apply to CPR and all other appropriate treatment and care for that individual should continue, says joint guidance published by the British Medical Association (BMA), the Resuscitation Council UK (RCUK) and the Royal College of Nursing (RCN).

‘It is important that this is widely understood by healthcare professionals and that it is made clear to patients and those close to them,’ says the guidance. ‘This is essential as it is a common fear among members of the public that a DNACPR decision will lead to withholding of other elements of treatment.’

Are DNACPR notices legally binding?

No, says the RCN in its COVID-19 guidance on DNACPR and verification of death.

‘Ultimately the decision to start or not to start CPR is a clinical judgement made at that point in time; the presence of a DNACPR recommendation will guide this decision,’ says the RCN.

Why would someone have a DNACPR notice in place?

The RCUK says there may be many reasons. CPR interventions are invasive and may create harmful side effects, including damage to internal organs and adverse clinical outcomes. Not attempting CPR may also mean a patient can die in a more dignified and peaceful way in their preferred place of care, rather than as an emergency hospital admission, says the General Medical Council (GMC).

What role do nurses play in DNACPR recommendations?

Recommendations about CPR and other emergency care should usually be made with the agreement of the senior responsible clinician, who may be a nurse with the appropriate knowledge and skills. In some care settings, a senior nurse may sign a recommendation about CPR and they may also record recommendations on behalf of the senior responsible clinician, says the RCN.

From the start of the COVID-19 pandemic, there have been concerns that DNACPR decisions have been made without properly involving people, their families or carers

What does good practice look like?

‘Anticipatory decisions about CPR are best made in the wider context of advance care planning before a crisis necessitates a hurried decision in an emergency setting,’ says the joint guidance.

The RCUK recommends using its recommended summary plan for emergency care and treatment (ReSPECT) process. This creates personalised recommendations for an individual’s clinical care and treatment in a future emergency in which they are unable to make or express choices. Recommendations are created through conversations between a person, their family and their healthcare professionals to understand what matters to them and what is realistic in terms of their care and treatment. Preferences and recommendations are recorded on a non-legally binding form that can be reviewed and adapted if circumstances change.

What should I do if I think a DNACPR notice has been recorded inappropriately?

Raise the issue with the clinician who has overall responsibility for the person’s care. They should always be prepared to discuss a CPR decision with you and any other healthcare professionals involved in the person’s care, says the joint guidance. Wherever possible and appropriate, a decision about CPR should be agreed with the whole healthcare team. If there is doubt or disagreement about the most appropriate decision, a second opinion should be sought.

Decisions should be reviewed frequently, especially when someone’s condition or their expressed wishes change.

Why have DNACPRs been controversial during the COVID-19 pandemic?

From the start of the pandemic, there have been concerns that DNACPR decisions have been made without properly involving people, their families or carers, and have been applied to groups of people in a blanket way, rather than taking into account an individual’s circumstances. Those particularly affected include people who are older, or who have dementia or a learning disability.

In a report published in March, the Care Quality Commission (CQC) heard the experiences of more than 750 people, which showed many were not supported enough in advance care planning conversations during the COVID-19 pandemic.

In some cases, people were not always aware that a DNACPR decision was in place, the report found. There were also cases where nurses felt unable to challenge the decisions of senior doctors.

DNACPR decisions should be reviewed frequently, and especially when a person’s condition changes Picture: iStock

At the height of the first wave in April 2020, the Nursing and Midwifery Council (NMC) and GMC issued a joint statement urging registrants to provide ‘thoughtful and compassionate handling’ of discussions about putting a DNACPR notice in place.

Charity Mencap has called for DNACPR notices to be reviewed and removed from the records of patients who did not give informed consent or where proper decision-making did not take place.

‘It is unacceptable that assumptions are made about people’s quality of life or their wishes in relation to treatment. They deserve and have a right to so much better,’ says Mencap head of policy Dan Scorer.


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