Consent and Ethics: Adults
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.
- British Medical Association (BMA) – Guidance on DNACPR
- Resuscitation Council (UK) – Resuscitation decisions
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 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.
ReSPECT - Recommended Summary Plan for Emergency Care and Treatment - ReSPECT is a process that creates personalised recommendations for a person’s clinical care in a future emergency in which they are unable to make or express choices. It provides health and care professionals responding to that emergency with a summary of recommendations to help them to make immediate decisions about that person’s care and treatment. ReSPECT can be complementary to a wider process of advance/anticipatory care planning.
- Fritz Zoë, Slowther Anne-Marie, Perkins Gavin D. Resuscitation policy should focus on the patient, not the decision. BMJ2017;356:j813
Below are more useful links and web resources which explore this topic in more detail:
- General Medical Council (GMC) – End of life resources
- Association of Anaesthetists – Guidance on DNACPR in the perioperative period
- British Medical Association (BMA) – End of life care and artificial nutrition
- BMA – Guidance on DNACPR
- BMA – Overview on end of life
- Leigh Day – The law surrounding consultation in DNACPR decisions (Tracey v Addenbrooks)
- A matter of life and death: The Medical Defence Union perspective on DNACPR
- NHS Scotland – integrated Adult Policy in Scotland: Do not attempt cardiopulmonary resuscitation
- Steinberg SM. Cultural and religious aspects of palliative care. In J Crit Ill In Sc 2011;1(2):154–156*
- London Mallee Regional Palliative Care Consortium – An Outline of Different Cultural Beliefs at the time of Death*
Useful podcasts dealing with case specific situations:
- Inside the Ethics Committee, BBC Radio 4 – End of life and Islam*
- Inside the Ethics Committee, BBC Radio 4 – Withdrawing treatment
Below is a link to an NHS Health Education England e-LfH e-learning module that deals with many of the issues addressed above:
*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