Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) Orders

Where possible, if a person is approaching end of life or has a serious progressive condition, an anticipatory discussion about whether to perform CPR should be initiated with the patient.

A person with capacity may refuse CPR. Similarly, an adult without capacity, but has an existing Advanced Decision that is directly applicable to their current situation may also refuse CPR. In both these cases the patient's wishes must be respected. When an Advanced Decision does not exist or there is limited information regarding a patient, the presumption should be for CPR to be performed should it be required. This stance may be revised as more information becomes available.

Anaesthesia presents some very specific challenges in patients who have a DNACPR order in place. Anaesthesia may be required for palliative operative procedures or some cardiac interventions. Due to the overlap of what represents safe anaesthetic practice and resuscitation due to the drugs and techniques involved and the risk precipitating cardiac arrests in this frail group it is often appropriate and recommended to temporally suspend or at least modify a DNACPR order during such procedures if it is thought that they are of benefit to the patient, but risk causing a reversible cardiac arrest. The decision to suspend (or modify) the order must be discussed with the patient or their proxy in advance of the procedure, clearly establishing what the patient would accept or refuse and what outcomes they would be most anxious to avoid (e.g. brief use of the defibrillator while under anaesthesia versus a protracted course in ICU post operatively). In 2009 the Association of Anaesthetists of Great Britain and Ireland (AAGBI) produced comprehensive guidelines on this subject.

When making decisions around the non-institution of CPR it is important to determine whether it is felt that CPR has any chance of sustainably restarting the heart and if so whether the result would be burdensome and the harms of doing so would outweigh the benefits.

 

Resources

 

Below are more useful links and web resources which explore this topic in more detail:

 

Useful podcasts dealing with case specific situations:

 

Below is a link to an NHS Health Education England e-LfH e-learning module that deals with many of the issues addressed above:

Please also see our End of Life Care section.

 

 

 

 


*We have tried to find freely accessible resources on the practices and processes of the different religions around end of life care. We would be grateful for any additions to this section. If you know of any helpful open access resources in this area please contact us here

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