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Understanding 'do not attempt resuscitation' orders.


VOL: 103, ISSUE: 15, PAGE NO: 26

Christine Penhale, BSc, RGN, is ALS instructor at the Resuscitation Council (UK)

Mandy Odell, PGdipEd, MA, RGN, is nurse consultant in critical care at the Royal Berkshire Foundation NHS Trust

There is an assumption that resuscitation will be attempted in all patients admitted to hospital who experience a cardiorespiratory arrest. Unless a valid ‘do not attempt resuscitation’ (DNAR) order or an advance directive (sometimes known as a living will) exists, every patient should be actively resuscitated. Following numerous press reports of poorly made and documented decisions about CPR, the government introduced guidelines on standards of practice when making these decisions (Smith et al, 2005). In 2001 joint guidelines by the Resuscitation Council (UK), the BMA and the RCN were published (RCUK et al, 2001). These give guidance on the decision-making process, including communication with patients and relatives.

The document Cardiopulmonary Resuscitation - Standards for Clinical Practice and Training (RCUK et al, 2004) was seen as the best advice on the matter by resuscitation officers.

The Human Rights Act had come into force in 2000, which underpinned the focus on patients’ right to dignity and respect, and freedom from degrading treatment.

Schofield and Watson (2002) agreed with the 2001 guidance that it is essential to identify patients for whom cardiopulmonary arrest represents a terminal event in their illness, and in whom attempted CPR would be inappropriate.

However, they added that it is essential to identify those patients who do not want CPR to be attempted, even though these decisions are complex, and may lead to misunderstanding and dispute among healthcare professionals.

Advance directives

An advance directive is a voluntary statement made by a competent person, relating to the refusal of treatment (Matesanz, 2006). Treatments commonly listed are mechanical ventilation, CPR, surgery and artificial hydration and nutrition. The purpose of an advance directive is to enable patients to refuse certain treatments or procedures in case they become incapacitated and unable to make these decisions.

The NMC states that advance directives are fundamental to the patient’s autonomy. Although advance directives have legal effect in common law, they are seen to be revocable, and any doubt over their validity should be resolved in favour of the preservation of life (Matesanz, 2006).

Healthcare professionals can face difficult situations where an advance directive (or living will) has been made by a patient who is no longer mentally competent. Their legal status is currently only protected by common law. This limits the choices that patients with debilitating illnesses have. They may lose capacity, and their wishes may be denied.

Mental Capacity Act

Further challenges will be faced by clinicians when the Mental Capacity Act comes into force in April 2007. The Act is intended to protect the most vulnerable in society, who may have mental illness, dementia, brain injury, acquired incapacity through a road traffic accident, stroke or another form of trauma.

It is not possible to predict what impact the act may have on practice. But as it will give relatives the right to be involved with end-of-life decisions, it may influence the communication of DNAR decisions.

Currently there is no such safeguard for people who lack mental capacity to make decisions about their care. The Mental Capacity Act enables competent adults to appoint a relative to make decisions on their behalf if they lose the ability to do so; previously the law only covered financial matters. There will be a code of practice for healthcare professionals who care for vulnerable people.

Vulnerable people who do not have a next-of-kin representative will be able to have representation from an advocate, through the independent mental capacity advocate (IMCA) service.

Age concerns

Increasing age should not be a deciding factor regarding resuscitation status. Age Concern and other organisations have campaigned for older people to be treated with dignity, and have repeatedly raised concerns about patients’ lack of involvement in the decision-making process.

Nurses need to develop the communication skills to include patients and relatives in the DNAR decision.

Decision-making and recording

Currently relatives do not have a legal right to make a decision about their loved one’s resuscitation status. However, it is considered good practice to consult with them on this issue.

It is also advisable to consult the team looking after the patient, including the patient’s GP, who all may contribute information that gives a more complete picture of the benefits and pitfalls of attempting resuscitation.

Any discussion that either the medical or nursing staff have with the patient or their relatives needs to be documented in the patient’s notes, with the names of people involved, a summary of the conversation, and details of the date and time.

The RCUK, in conjunction with the BMA, Age Concern and the RCN, has compiled a patient and relative information leaflet, which is available at the website. This can be amended locally, and then given to patients and relatives to provide full explanations of the terms.

Should a decision not have been discussed with the patient and others close to them, then it must be documented with a rationale, especially as this can be a contentious issue when reviewing notes following complaints about patient involvement in DNAR decisions.

Guidance on CPR

The joint statement published by the RCUK et al (2004) makes the following recommendations on discussions regarding a patient’s resuscitation status:

1. It is essential to identify (a) patients for whom cardiopulmonary arrest is an anticipated terminal event and in whom cardiopulmonary resuscitation (CPR) is inappropriate; and (b) patients who do not wish to be treated with CPR.

2. All institutions should ensure that there is a clear and explicit resuscitation plan for all patients. For some patients this will involve a ‘do not attempt resuscitation’ decision. Such decisions are complex clinically, ethically and emotionally. National guidelines from the BMA, RCUK and the RCN provide a framework for formulating local policy. The institution should have a written policy about resuscitation decisions (including ‘do not attempt resuscitation’ decisions) that is available to all clinical and managerial staff. 

3. Where there is no resuscitation plan and a patient’s wishes are unknown, resuscitation should be initiated if cardiopulmonary arrest occurs. A decision not to attempt resuscitation may be appropriate when:

- The patient’s condition indicates that effective CPR is unlikely to be successful;

- CPR is not in accord with the recorded wishes of a mentally competent patient;

- CPR is not in accord with an applicable advance directive (living will). Such directives are legally binding in England and Wales;

- Successful CPR is likely to be followed by a length and quality of life that is not in the best interests of the patient.

4. The overall responsibility for a ‘do not attempt resuscitation’ decision rests with the most senior doctor in charge of the patient. The opinions of the members of the medical and nursing team (including the GP), the patient and the patient’s relatives, when appropriate, should be taken into account when making the decision.

5. The most senior available member of the medical team should enter the ‘do not attempt resuscitation’ decision and the reasons for it in the medical records. It should also be documented whether the patient and relatives have been informed, and their comments noted. If no discussion has taken place, the reasons for this should be documented. Use of a dedicated ‘do not attempt resuscitation’ form is encouraged.

6. The ‘do not attempt resuscitation’ decision should be communicated effectively to all members of the multidisciplinary team involved in the patient’s care. It should be reviewed regularly if there are changes in the patient’s condition. The decision should be clearly documented in the nursing notes, and handed on to staff at the change of each shift.

7. A decision not to attempt resuscitation applies only to CPR. It should be made clear to the patient, people close to them and members of the healthcare team that it does not imply ‘non-treatment’ and that all other treatment and care appropriate for the patient will continue to be considered and offered.

8. The institution should provide information for staff, patients and relatives about its resuscitation decisions.


Even though the guidance from the RCUK and the patient information leaflet on CPR decisions is a valuable resource, there is still scope for improvement in decision-making, documentation and audit relating to CPR.

Learning objectives

- Develop a full understanding of what an advance directive is

- Be aware of the Mental Capacity Act and its possible impact

- Know the protocols for decision-making and recording

- Know the recommendations in best practice guidance from the Resuscitation Council (UK)

Guided learning

- Outline the issues that influence the making of a ‘do not attempt resuscitation’ order

- Explain what an advance directive is

- Outline how the Mental Capacity Act might affect the issue of ‘do not attempt resuscitation’ orders

- List the recommendations in the Resuscitation Council (UK)’s guidance on clinical practice and training

This article has been double-blind peer-reviewed


Readers' comments (3)

  • My mothr (86) has recently been admitted into the QAH, at Portsmouth, Hampshire, fters an episode of ''rigors'', and where she iscurrently being treated for dehydration, UTI, low Hb.
    She hs had several admissions into both QAH and SMeGH, in Portsmouth over the past 12months, and has been dischareged home, albeit with nursing support care.
    Mentally, she has always been alert, orientated in time, place and person; and apart from being forgetful at times, can hold a reasonable conversation with the best of them.
    When I went to discuss her progress with the staff nnurse she red me her latest doctores assessment of her, and to my horror, I read the instruction:- 'Not For Resuss'. Somewhat shocked by what I had just read I questioned the reason, and whose decision. She told me, politely, that the desion had been made by the Doctors, who had '' obviously'' discussed the matter with my mum, who, ''must hve agreed to it''.
    When I questioned eveidence of my mum's consent, she told me that they were ''covered ''by a ''form'', which she showed me, but there was no signture from my mum anywhere on it.

    What I'm concerned about is are doctors legally permitted to make such important decisions about their patients emergency care, which after all is the final one , in my mum's case, to end her life without attempting to save her.

    When I did my generl nursing training, in the 1970's, the practice was to stick circulr coloured disc on the patients notes, which was to indicate that the patient was not to be resucitated. Needless-to-say, I disapproved of this practice, and always advocated that such a decision should only be made on the patients state of health and prognosis, not because he or she was, simply,old.
    Incidentally, I realise that if my mother has, infact, discussed the matter of resucitation, with the doctors in charge of her care, and, agreed to it, there would be no issue as far as I'm concerned. However, if she did, why isn't there any evidence of it written in the note to indicate she had?

    Yours faithfully,
    Les Clark, RMN,SRN, CPN Cert.

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  • Further to my letter, above, I can reveal that after discussing the matter of resucitation, at length, with the doctor responsible for my mother's care, my mother has since been approached by one of the nurses on the ward and been informed of the action - or lack of it in my mum's case - the medical staff will take should she 'cardiac arrest'.
    She will be allowed to die of, ''natural causes'' - her own choice.
    Needless-to-say, I learned this information from my wife, not from either the doctor or nursing staff. So no change there the, eh?

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  • Conclusion

    My mother was finally discharged back home, where, she discussed her future nusing care mngement with both her GP, NHS Care Team and the Mcmillan nurses.
    Apparently, she decided to decline any further hospitalisation, and would have her on going 'treatment'.
    Consequently, she died, peacefully, on the 29th September 2009, at home in her bed . My wife and I were both present at the time of her death, and thus fulfilling her last request.

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