DNACPR Questions For CPD

If adults have capacity to make decisions about how their clinical information is shared, their agreement must always be sought before sharing information with others, including family and friends.

Where there is a clear clinical need for a DNACPR decision in a dying patient for whom CPR offers no realistic prospect of success, that decision should be made and, where appropriate, explained to the patient and those close to the patient at the earliest practicable opportunity (2014:5) Triggers for DNACPR review should include any request from the patient or those close to them, any substantial change in the patient’s clinical condition or prognosis and transfer of the patient to a different location (including transfer within a healthcare establishment).

If adults have capacity to make decisions about how their clinical information is shared, their agreement must always be sought before sharing information with others, including family and friends.

A decision not to attempt CPR applies only to CPR. All other appropriate treatment and care for that person should continue. It is important that this is widely understood by healthcare professionals and that it is made clear to patients and those close to them. This is essential as it is a common fear amongst members of the public that ‘DNACPR’ applies to all elements of treatment. Inclusion of decisions relating to CPR as part of an advance care plan or treatment escalation plan may help to emphasise which other treatment options are and are not appropriate for each individual, but quality of care should not be limited by any such plans or decisions.

If cardiorespiratory arrest occurs in the absence of a recorded decision there should be an initial presumption in favour of attempting CPR. Since a DNA CPR decision is one which will potentially deprive the patient of life-saving treatment, there should always be a presumption in favour of patient involvement

It is imperative that clinicians record discussions regarding treatment and DNACPR notices, and particularly so in cases where the treating team is of the view that it would be inappropriate to involve the patient in the decision making process as it would cause actual physical or psychological harm not just distress

Making a decision not to attempt CPR that has no realistic prospect of success does not require the consent of the patient or of those close to the patient (2014:4) Clinicians should however consult even if they feel the treatment would be futile. A patient is entitled to know when a clinical decision has been taken. If they are not told, they will be deprived of the ability to take a second opinion.

Patients have no legal right to treatment that is clinically inappropriate. Sometimes patients or those close to them will try to demand CPR in a situation where it is clinically inappropriate. If the healthcare team has good reason to believe that CPR will not re-start the heart and breathing, this should be explained to the patient in a sensitive but unambiguous way.(2014:11)

Great care must be taken when people other than the patient make or guide decisions that involve an element of quality-of-life assessment, because there is a risk that healthcare professionals or those close to the patient may see things from their own perspective and allow their own views and wishes to influence their decision, rather than those of the patient. These considerations should always be undertaken from the patient’s perspective.(2014:16)

If the DNACPR form is not completed in it’s entirety it can leave both clinicians and the trust open to legal challenges as in the Tracy Case. The DNACPR form is a commonly accepted documentation format and the old adage ‘..if it isn’t written down it didn’t happen applies in this case..’

If the patient does not want to discuss his/her condition and treatment and has capacity the clinician should respect and document their wishes. Discussion with those close to the patient may be used to guide a decision in the patient’s best interests, unless confidentiality restrictions prevent this.

If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable advance decision refusing treatment (ADRT), specifically refusing CPR, this must be respected.