Debate: Do Not Attempt Resuscitation orders

Item referred to Council  

Do Not Attempt Resuscitation (DNAR) orders (and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders in Scotland) are used to provide guidance to health care professionals on the action to take should the patient in their care suffer a cardiac arrest or stop breathing for any reason.

Effective communication – and recording of that communication – is fundamental to the work of health care professionals in the delivery of care to patients and their families and carers. Anecdotal evidence suggests that appropriately timed conversations about DNAR/DNACPR orders between health care staff and their patients do not always take place. Consequently, these patients and their families and carers are not being fully consulted on decisions about cardiopulmonary resuscitation (CPR) intervention in advance. This area of concern was highlighted by the Parliamentary and Health Service Ombudsman (2015) report which noted that health care professionals do not always have open and honest conversations with patients and family members and carers.

The NHS Constitution for England (Department of Health, 2015) indicates that people have the right to be involved in discussions and decisions about their health and care and given the information to enable them to do so; this includes end-of-life care, and, where appropriate, this right extends to their family and carers. The constitution also reflects the fact that all people can expect to be treated fairly And the NHS Scotland Charter of Patients’ Rights and Responsibilities, backed up in legislation, states: “you have the rights to be involved in decisions about your care”. 

NICE guidelines on End of Life Care for Adults sets out the standard of good communication and shared decision making with patients, families and health care professionals. 

Guidance published jointly and reviewed by the British Medical Association, Resuscitation Council (UK) and the Royal College of Nursing places a great emphasis on ensuring high-quality communication, decision making and recording in relation to decisions about CPR. No matter how difficult the conversation, health care staff must discuss the issue of CPR interventions with their patients and/or their families or carers.

In Scotland, the national integrated policy guidance Decisions Relating to Cardiopulmonary Resuscitation (Scottish Government, 2016) clearly sets out the standards of communication for health care staff. Similar to guidance in England and Wales, it indicates that if CPR is unlikely to be successful it is important that this is communicated sensitively to the patient, unless it is judged that the conversation would cause physical and psychological harm. If the patient lacks capacity, the relative or carer must be informed.

Conversations relating to DNAR/DNACPR orders should be part of a wider person-centred conversation about a patient. DNAR/DNACPR orders not only provide a platform for open communication about possible end of life interventions, but it also helps to demystify the dying process, empowers the patient and is at the heart of shared decision-making.