The three key principles behind clinical decisions on resuscitation

While do not attempt cardio-pulmonary resuscitation (DNA-CPR) forms are relatively common, they can often be a source of confusion and misunderstanding.

DNA-CPR orders actually have no formal legal basis. They are merely documentary evidence of a decision that has been made by the clinical team. The actual decision can be made for different reasons and it is essential that anyone presented with such an order understands why it has been made.

Three different principles could underlay any particular decision and these can best be described as:

• Futility – where the patient’s condition indicates that CPR is unlikely to be successful;
• Best interests – where successful CPR is likely to be followed by a lengthened quality of life which would not be acceptable to the patient;
• Advance decision – where CPR is not in accord with the recorded wishes of the patient who is (or was at the time of the decision) mentally competent.

Futility

This is where, in the opinion of the treating clinicians, CPR will not re-start the heart and maintain breathing. In such circumstances performing CPR will be futile and should not be done.

Guidance from the British Medical Association, the Resuscitation Council and the Royal College of Nursing published in October 2007, makes that clear: “In some cases, the decision not to attempt CPR is a straightforward clinical decision. If the clinical team believes that CPR will not re-start the heart and maintain breathing, it should not be offered or attempted. CPR (which can cause harm in some situations) should not be attempted if it will not be successful.”

If, on the basis of all the information available, a practitioner is confident that CPR would be futile, there is no duty upon them to perform it. This will most commonly arise when a patient is in the final stages of an incurable illness.

Best interests: benefits v burdens

While in some cases CPR may be successful in re-starting the heart and breathing for a sustained period, an evaluation of the benefits of prolonging life versus the potential burdens to the patient will conclude that it is not in the patient’s best interests to receive CPR.

Where a patient lacks capacity decisions must be made on their behalf on the basis of what is in their best interests. This is wider than simply medical interests and encompasses medical, emotional and all other welfare issues. Clinicians have been supported by the courts in their conclusions that it will not be in the best interests of a patient to give or continue with medical treatment, even where the consequence will be the death of a patient.

The same principle will apply to CPR. The Joint Statement Guidelines confirm that a decision that CPR will not be attempted, on best interests grounds, because the burdens outweigh the risks should be made after careful consideration of all the relevant factors and discussion with the patient (or their close relatives if the patient lacks capacity).

It is very unlikely that a proper assessment of these issues can be made in an emergency setting. Where no explicit decision has been taken and documented, healthcare professionals should make all reasonable efforts to revive a patient in the event of a cardiac or respiratory arrest.

Advance decision

Many DNA-CPR decisions are made expressly in accordance with the wishes of a patient. In effect, they are advance decisions covered by the Mental Capacity Act 2005. Under the Act, an advance decision refusing treatment will only be valid and therefore legally binding on the healthcare team if it complies with the strict criteria laid down under the Act.

To validly refuse life sustaining treatment an advance decision must:

• Be in writing (it may be written by someone else or recorded in the healthcare notes)
• Be signed and witnessed
• State clearly that the decision applies even if life is at risk

Before relying on such a document it must be determined whether the patient:

• Has done anything that clearly goes against their advance decision
• Has withdrawn their decision
• Has subsequently conferred the power to make that decision on an attorney
• Would have changed their decision if they had known more about the current circumstances

Unless a decision meets these criteria, it will not be binding. Where it does not meet these criteria, the decision should still be taken into account in determining what is in the patient’s best interests.

A DNA-CPR order is merely evidence that a decision has previously been made concerning whether CPR should be given to a patient. There are different reasons why such a decision may have been made. Understanding that decision will help healthcare professionals to act appropriately and this should be clearly set out on the form itself.

Clinicians will need to be sensitive to family and friends who may be present but should be confident in making decisions on the basis of their training and professional judgment.