What is a DNACPR / DNAR document?

What is a DNACPR decision?

If your heart stops beating or you stop breathing, medical professionals may attempt an emergency procedure to bring you back to life. But in some circumstances this may do more harm than good. A ‘do not attempt resuscitation’ (DNAR) decision instructs medical staff on whether or not they should attempt to resuscitate you. There is often confusion about how these decisions are made and when they can be used.

A DNAR decision is a written instruction to medical staff not to attempt to bring you back to life if your heart stops beating or you stop breathing. It’s also referred to as a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decision, or a DNACPR order.

A doctor is likely to recommend a DNAR decision be issued if they feel that resuscitation is unlikely to be successful or may even cause you harm. The decision is usually recorded on a special DNAR form, completed by a doctor. The form makes it easy for health professionals to quickly recognise a DNAR decision in an emergency. The form only covers CPR, so if you have a DNAR form you’ll still be given other treatment and care to ensure you are pain-free and comfortable.

In the past, this process was often called a ‘do not resuscitate’ (DNR) order. But this phrase is now considered inaccurate, as there’s no guarantee that resuscitation will be successful and the decision is actually about whether it should be attempted in the first place.

Who can make a DNAR decision?

Only a doctor can make a DNAR decision or issue a DNAR form. But whenever possible they should do this in consultation with you or those close to you. You can’t make a DNAR decision yourself, but you can request that your doctor issues one and they should normally carry out your request. Also, if you don’t want to receive CPR, you can state this in an ‘advance decision to receive treatment’ (ADRT), which would then be legally binding. It’s possible in some circumstances that a doctor might issue a DNAR order even if you or your family don’t agree with the decision.

For example, if the doctor is convinced that the damage of CPR would outweigh any potential benefit. However, it’s more likely that they would take your preferences into account. Your healthcare team should also give you the opportunity to ask for a second opinion if you disagree with their decision. If you haven’t stated a preference about CPR in advance, your medical team is responsible for making a DNAR decision. But they have a duty to discuss the decision with you.

You can refuse CPR even if there is a chance that it may help you. If you cannot make decisions for yourself, for example because you are unconscious or unable to communicate, the doctor should talk to your family or carers about your likely wishes. However, your family and friends are not allowed to decide that you shouldn’t be resuscitated, unless you have given them the legal power to do so through a Lasting Power of Attorney.

What is CPR - cardiopulmonary resuscitation?

Cardiopulmonary resuscitation (CPR) involves physically attempting to restart your heart.

It can involve:

chest compressions (repeatedly pushing firmly on the chest) inflating the lungs (by inserting a tube into the windpipe or by placing a mask over the mouth and nose)
Defibrillation (using electric shocks to correct the heart’s rhythm).
It can be distressing, especially for loved ones, and in some cases, CPR can cause injuries such as punctured lungs, broken ribs and bruising.
CPR is a violent, aggressive treatment, and may not help you live much longer, or may bring you back to life but with severe damage, into a very restricted life.

Why would a DNAR decision be needed?

DNARs are designed to protect people from unnecessary suffering by receiving CPR that they don’t want, that won’t work or where the harm outweighs the benefits.

In making the decision, a doctor must weigh up the risks and benefits of CPR for each individual.

That includes:

Whether CPR is likely to be successful. Only around one in five CPR attempts in hospital are successful and even fewer outside a hospital.
Whether someone is coming close to the end of their life. In these circumstances CPR could be unwelcome and upsetting for the individual and their family.
Whether it will lead to poorer quality of life. For example, in some cases you can be left with permanent brain damage or in a coma.

Are DNAR forms legally binding?

Technically, a DNAR form is not a legally binding document, but medical staff should abide by it once a form is in place. If you don’t want to be resuscitated and want this to be recorded in a legally binding document, you should make an advance decision to refuse treatment. For extra certainty, you should also ask for it to be recorded on a DNAR form.

Telling others about your DNAR form

Your DNAR form needs to be available in an emergency so that any professionals caring for you know it exists. If you’re in hospital, the form will be kept with your notes. If you’re sent home, you should give a copy to your GP to keep with your records.

You should also tell family members or carers about it, and where it’s kept. This helps to avoid conflict between medical professionals and family members.

You can also ask for a DNAR to be recorded in your emergency care plan (ECP), if you have one. ECPs are drawn up by medical professionals in discussion with you. They are designed to provide easily accessible, brief clinical recommendations for use in an emergency. They are usually put in place for people with complex health needs, life-limiting conditions or illnesses that can suddenly deteriorate or cause heart failure.

Improving the DNAR decision process

Some problems have been identified with the use of DNAR decisions, including misunderstandings, poor communication and inconsistent recording. The ReSPECT process is a new emergency care plan procedure that is being piloted in the UK. You might come across it in your local area.

It aims to:

encourage better conversations between doctors and patients about CPR
prompt discussion about the aims of end of life treatment
help doctors understand better which treatments you wouldn’t want to receive in an emergency
record preferences in a simple format that medical staff can easily access.