Data from Peter English - Curated by EPG Health - Last updated 07 April 2017

Decisions to start cardiopulmonary resuscitation (CPR), or to decide in advance to issue a "do not attempt (cardiopulmonary) resuscitation" (DNAR) notice have always been a hot topic in clinical medicine. It may have become even more so since a recent (June 2014) court decision.

This conflates many issues, including:

  • The fact that CPR may be valuable in patients who have a treatable, cardiac event (though the success rate is considerably lower than many people believe - perhaps influenced by popular TV dramas).
  • The right of a patient with capacity to refuse a decision considered to be in their best interests. (This can form part of an advance directive.)
  • The difficulties faced by staff who do not know about the condition of a patient who has a cardiopulmonary arrest and who therefore feel obliged to institute CPR, even for patients who were dying, and for whom it is futile.

While performing CPR is of course worthwhile when it has a reasonable chance of success in the short term, and the patient has a reasonable chance of recovery, there have been concerns that it has been used where patients have no chance of recovery. There have been cases of patients who are receiving terminal care, and for whom CPR is instituted when their heart stops - which means they suffer what many consider a violent, undignified and distressing death, instead of a peaceful one. Indeed, it is perhaps a little surprising that no healthcare worker has ever (to my knowledge) been sued for assault after providing DNAR when it was futile and inappropriate. (It is only slightly surprising; in general the courts are far more lenient towards those who do something with good intentions, however inappropriate, than they are to those who are alleged to have not done something that somebody considers might have been appropriate.)

Nevertheless, many organisations will insist that, unless there is a DNAR notice in a patient's notes, all non-medical staff, and any doctors who do not know the patient's condition, are obliged to institute CPR if their heart stops, even for patients in whom this is clearly futile. This places pressure on all involved to ensure that a DNAR notice is placed in the notes of such patients.

Issuing a DNAR notice may, in itself, be distressing, however. Following the legal ruling I mentioned above it may seem necessary to discuss every DNAR decision with patients and/or their relatives. 

In fact, however, the full judgement is far more nuanced than it may have appeared from the press coverage. If it is considered that discussing a DNAR decision with the patient and/or their relatives would in itself be harmful (e.g. through causing undue distress), then a DNAR decision may be made without any such discusion. The decision-making process and the factors considered must, however, be carefully documented in the patient's notes to avoid the possibility of a successful legal claim by distressed relatives.

There is no legal obligation to discuss anything with relatives; but discussing a DNAR decision with them in advance may mean that they are less distressed at the time of death, and less likely to have unrealistic expectations. Indeed, the fact that relatives are sometimes upset when CPR is not performed may indicate that healthcare workers are not always as good as they could be at communicating to relatives how close to death a dying patient is (although it may also be much more complicated than that).

[This post is a re-working of text I originally wrote for the medical wiki ganfyd and on my blogspot blog.]


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