The recent inquest into the death of care home resident Joyce Parrott highlights the importance of organisations having clear procedures and policies in place for emergency medical events where cardiopulmonary resuscitation (CPR) may be given.
Do not attempt cardiopulmonary resuscitation (sometimes known as DNRs/DNARs but referred to here as DNACPR) is a record of an agreed care plan, made between an individual (or next of kin/person with Lasting Power of Attorney) and a medical professional involved in their care. The plan details whether CPR should be attempted in advance of a medical emergency where the individual will be unable to make a decision. There have been ongoing concerns raised about DNACPR decisions, which were heightened by the pandemic where decisions were being applied to groups of people rather than an individual’s personal circumstances.
Are DNACPRs legally binding?
A DNACPR is not legally binding and is a tool to guide decision-making, which should normally be respected. Guidance from the British Medical Association and Resuscitation Council UK states that 'overall clinical responsibility for decisions about CPR, including DNACPR decisions, rests with the most senior clinician responsible.'
Should an individual wish for a DNACPR decision to be legally binding, an Advance Decision to Refuse Treatment (ADRT) should be made. An ADRT can outline an individual’s refusal to receive a specific type of treatment in the future. There is no universal ADRT form, however, in order to be valid, it must meet a specific criterion outlined in section 24 of The Mental Capacity Act 2005. Many organisations and charities provide templates which can be used.
Who should make the decision?
Medical professionals responding to an emergency medical event have the responsibility of assessing the person’s immediate situation and may make a decision to go against a DNACPR if they believe it to be appropriate and justified.
Although organisations will have members of staff who are first aid trained or even medically trained, there may be difficulties in identifying a cardiopulmonary arrest, especially under the intense pressure of a medical emergency.
There may also be scenarios that do not match the situations detailed in a DNACPR such as someone developing cardiac or respiratory arrest from a readily reversible cause such as choking or a blocked tracheal tube. Guidance states that 'in such situations, CPR would be appropriate, while the reversible cause is treated, unless the person has made a valid refusal of the intervention in these circumstances.'
- Decisions around DNACPRs should always be person-centred and compassionate. Providers should keep comprehensive records of conversations.
- DNACPRs should be clear, have a suitable agreed written procedure in the event of a medical emergency and be available immediately and easily to all healthcare professionals.
- The location of emergency medical equipment such as defibrillators should be known to staff and easily accessible.
- Where no explicit decision about CPR has been considered and recorded in advance, there should be an initial presumption in favour of CPR.
- Decisions about CPR should be made by the most senior clinician responsible.
- Care providers must have appropriate policies and procedures in place concerning DNACPRs and provide education and training for care staff working in environments where cardiac arrests are likely.
- DNACPRs are complex and may give may rise to a civil claim where not adhered to.
Should you require advice or guidance on this topic, please contact the regulatory team.