Tough conversations about DNACPR decisions
Doctors must involve patients and those close to them in decisions about cardiopulmonary resuscitation, updated guidance says
Recent legal challenges have prompted new guidance for doctors on when they should have conversations with patients about decisions on cardiopulmonary resuscitation.
Judgments from two court cases say patients should be consulted about do not attempt cardiopulmonary resuscitation (known as DNACPR) decisions, unless the doctors believe consultation would cause them harm (box 1). The second judgment made clear that if patients lack capacity, their family should be consulted instead—even if this means a difficult telephone discussion in the middle of the night (box 2).
Box 1: Tracey case
Janet Tracey, who had lung cancer and a predicted life expectancy of nine months, was admitted to Addenbrooke’s Hospital with a broken neck after a road incident. She had chronic breathing difficulties and was placed on a ventilator. Unsuccessful efforts were made to wean her from the ventilator. She was communicating with staff by writing on a notepad and had expressed a wish to be involved in her care. Her condition deteriorated. One doctor placed a DNACPR notice on her notes at the same time another attempt was made to remove the ventilator. This attempt was successful. Her daughter discovered the DNACPR notice and protested, and it was removed. After Mrs Tracey’s death, her husband brought a case against the hospital. The court of appeal found that the hospital should have consulted Mrs Tracey before placing the notice.
Box 2: Winspear case
Carl Winspear, who had cerebral palsy and other comorbidities, was admitted to Sunderland Hospital with a chest infection. He did not have capacity to make decisions about his medical care. His mother was his primary carer. Around 3 am a doctor wrote a Do Not Attempt to Resuscitate (DNARes) notice on his notes, with a note to speak to the family the next day. The next morning Mrs Winspear was asked to speak to doctors before visiting Carl. The subject of a DNACPR notice was raised, and she objected. The notice was cancelled. She brought a case against the hospital after discovering that the notice had previously been made. The court found that Mrs Winspear should have been informed before the DNARes notice was put on her son’s notes.
Although the final decision about whether to perform any medical procedure lies with doctors, the guidance published by the BMA, Resuscitation Council (UK), and Royal College of Nursing now says more explicitly “there must be a presumption in favour of explaining the need and basis for a DNACPR decision to a patient.”
What is CPR?
Cardiopulmonary resuscitation (CPR) is an attempt to restart the circulation and breathing of someone whose heart or breathing has stopped. In hospital, CPR can include:
- Intubation of the patient to ventilate the lungs
- Chest compressions
- Delivery of high voltage electric shocks across the chest
- Injection of drugs, including adrenaline, to attempt to restart the heart.
CPR was developed in the 1960s as a treatment intended to restart the heart of people with sudden cardiac arrest (most commonly triggered by acute myocardial infarction), from which they would otherwise have been expected to make a good recovery. Use of CPR has now broadened considerably. It is sometimes used when people have a terminal illness and in situations when it is unlikely to work or might restore heart function for only a brief period, potentially prolonging patients’ suffering.
Shouldn’t everybody be resuscitated?
CPR can be an invasive and violent treatment that denies patients a dignified death. Fractures of the ribs and sternum are common, and there is a risk of internal injuries to other organs and long term neurological damage.
In the UK, hospital based resuscitation teams attempt CPR in around 20 000 patients each year. In 45% of those patients the heart will restart and beat for longer than 20 minutes. However, only 15% to 20% of people who have CPR in hospital after cardiopulmonary arrest survive to be discharged. 
Because of the potential for harm, anticipatory decisions to withhold CPR are used where CPR would be clinically inappropriate or contrary to the wishes of the patient. The discovery that in some cases decisions about CPR were being made without the knowledge or involvement of patients or their relatives is behind the recent court cases challenging these decisions (see boxes 1 and 2).
Who can make a DNACPR decision?
Decisions about CPR can be made by both patients and doctors, but, except where there is a valid advance refusal, the overall clinical responsibility rests with the most senior doctor responsible for the patient’s care. In some circumstances, a doctor may believe there is no realistic prospect of a successful outcome, in which case it would be clinically inappropriate to offer or attempt CPR. It is a well established legal principle that doctors are not obliged to offer or deliver interventions that will not be of clinical benefit to the patient. In many other cases, the decision about CPR is based on a balance of benefits and harm. If there’s a chance of success, the potential benefits of prolonging life must be balanced against the potential long term harms of CPR, and here there is a presumption in favour of involving patients or, where they lack capacity, those close to them in the decision making process.
What’s different about the new guidance?
The guidance re-emphasises the importance of high quality and timely communication, decision making, and record keeping. It states that doctors should enter an open and honest dialogue with patients and those close to the patient about what CPR entails and its possible risks, the chances of success, whether prolonging life is beneficial in all cases, and what constitutes a dignified death. Doctors need to explore patients’ views about what an acceptable quality of life means to them. If there is no realistic prospect of a successful clinical outcome, doctors should still explain to patients the reasons behind any DNACPR decision.
Discussion about CPR decisions can cause major distress. For some patients it will be the first time they have considered the end of life. A decision not to resuscitate can be misinterpreted as doctors “giving up” on patients. Such conversations can equally be difficult for doctors.
The 2014 case of Tracey (box 1) made clear that patients are entitled to know that a DNACPR decision has been made, and the fact that such a conversation may be distressing is not sufficient justification to delay or not have it. Doctors must now discuss DNACPR decisions unless there is a “particularly convincing justification” not to, such as the likelihood of causing patients “physical or psychological harm.”
A 2015 case, Winspear (box 2), found that the inconvenience of discussing the situation with a patient’s carer was not a “particularly convincing justification.” In this case, the court indicated it would have been appropriate for the doctor who recorded a DNACPR decision in the notes of a young man who lacked capacity to speak to the man’s mother, even though this would have meant phoning her at 3 am.
The realities on the ground
Although the new guidance sets out the ideal approach to discussing DNACPR decisions, the realities of putting them into practice are not always straightforward. Some problems for doctors remain.
- What is the threshold for “physical or psychological harm” that would be sufficient for doctors to decide not to talk to patients about DNACPR decisions?
- In what circumstances might it not be “practical and appropriate” to consult with patients or their carers about these decisions?
- The new guidance states that doctors should have discussions about DNACPR with all patients at risk of deterioration or approaching end of life, even if CPR would be clinically inappropriate.
- What should happen if patients or relatives disagree with a doctor’s DNACPR decision? How should doctors resolve that conflict, especially where performing CPR is likely to have no clinical benefit? How do you balance talking to patients about the benefits of having a dignified or peaceful death versus an invasive intervention that may prolong life but potentially cause more harm?
- Although a DNACPR decision lies with the most senior clinician responsible for a patient’s care, it is often junior colleagues who make up the crash team and are responsible for delivering CPR. A patient could express a wish to receive CPR against medical advice. If this is accepted by the consultant, then the crash team may be providing an intervention that they would disagree with and would not provide, had they had all the information.
- Which patients should doctors consider for a DNACPR discussion, and at what point in their care? Should this be at the point of admission, and if so, who should be in charge of recording it?
- How should these decisions be recorded? Currently, no standardised form for documenting DNACPR decisions exists. Work is ongoing on a national form for recording preferences about emergency care, including decisions about CPR, called the Recommended Summary Plan for Emergency Care and Treatment (or ReSPECT).
- Will the court judgments motivate hospitals to find ways to record patients’ resuscitation wishes earlier (at the point of admission, for example)? Who should be responsible for having these conversations, how should the information be recorded, and how will this impact on clinicians’ workload?
- Or will these rulings make doctors less proactive in seeking patients’ views on resuscitation? This could mean staff are less likely to complete DNACPRs, which could lead to an increase in inappropriate resuscitation attempts.
- CPR can saves lives, but it is an invasive and sometimes traumatic intervention that can cause substantial harm.
- Conversations about whether to perform CPR can be difficult for doctors and patients.
- The new guidance says if there is a chance that CPR may be successful, patients or those close to them should be involved in the decision making process and given an overview of the benefits and harms.
- If a doctor believes the procedure will not be successful, he or she should explain to the patient the reasons behind their decision not to perform CPR.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- British Medical Association, Resuscitation Council (UK), Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation. 3rd ed, 1st revision. 2016. www.bma.org.uk/advice/employment/ethics/ethics-a-to-z/decisions-relating-to-cpr.
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- Burke v GMC  EWHC 1879 (Admin).
- R (Tracey) v Cambridge University Hospitals NHS Foundation Trust  EWCA Civ 822.
- Winspear v City Hospitals Sunderland NHS Foundation Trust  EWHC 3250.
- Resuscitation Council (UK). Recommended summary plan for emergency care and treatment consultation. June 2016.