The Use of DNAR Orders
Cardiopulmonary resuscitation (CPR) may be inappropriate in the following circumstances:
- Illness with known poor prognosis
- Where it is against the declared wishes of a mentally competent patient
- Where it is not in accord with a valid applicable advance directive
- Where attempting CPR will not restart the patient's heart and breathing
- Where there is no benefit in restarting the patient's heart and breathing
- Where the expected benefit is outweighed by the burdens.
In these circumstances it is appropriate to consider whether in the event of
a cardiac arrest active resuscitation should be attempted.
A DNAR decision relates ONLY to resuscitation - NOT to any other treatment
Making a DNAR Decision
Ideally, decisions about whether to attempt to resuscitate a particular patient
are made in advance as part of overall care planning for that patient and, as
such, are discussed with the patient along with other aspects of future care.
A DNAR decision should be made only after appropriate consultation and consideration
of all relevant aspects of the patient's condition.
These include:
- The likely clinical outcome of a resuscitation attempt, including the likelihood
of successfully restarting the patient's heart and breathing and the overall
benefit achieved from a successful resuscitation.
- The patients known or ascertainable wishes.
- The patients Human rights including the right to life and the right to be
free from degrading treatment, the right to be free from discriminatory practices,
the right to hold opinions and receive information and respect for privacy.
With due regard to the above a DNAR decision
- Should be made by Consultant in Charge of case.
- If the consultant is not immediately available this responsibility may be
delegated to a Registrar or other middle grade staff holding a substantive
trust post
- If delegated, the Consultant MUST review the decision within 24 hours.
- Opinions of the patient, family, nursing and medical staff may all be valuable
when considering the decision.
- The decision must be discussed, in the presence of a senior member of the
nursing team with:
- Patient (if mentally competent) and with due regard to the patients wishes
as to confidentiality
- Relatives (preferably both if possible)
- If the patient cannot express a view (ie is mentally incompetent) the views
of family or others close to the patient should be sought as to what the patient's
wishes would be. Their role is to reflect the patient's wishes, not to take
decisions on behalf of the patient.
- These discussions with patient and relatives should include a clear explanation
of what is involved in a cardiac arrest and in attempted resuscitation as
well as accurate information about outcomes.
- Patient and relatives must be given the opportunity to ask questions during
the discussion and at a later time.
- A record of any such discussions must be documented in the patient's medical
case notes. Information should not be forced on unwilling recipients. Where
patients indicate a clear desire to avoid such discussion this should be recorded
in the patient's case notes.
- Rarely it may be considered inappropriate to discuss the decision with the
patient. It if is deemed inappropriate to discuss a DNAR decision with either
the patient or relatives, this must be documented, with reasons why. Health
professions must be prepared to justify their actions. Staff reluctance to
discuss DNAR issues is NOT a sufficient reason.
- Where following discussion and explanation a patient asks that no DNAR order
is made this should be respected.
- Doctors cannot be required to give a treatment which contrary to their clinical
judgement as to what is in the patient's interests. Doctors must be prepared
to justify such decisions.
Recording and Communicating a DNAR Decision
The decision must be recorded together with the reasons for the decision in
the current medical case notes.
Notes must be signed and dated by the person making decision who is responsible
for ensuring the decision is communicated to others.
The Resuscitation Status Review Sheet should be completed and placed at the
front of the case notes.
The decision must be reviewed regularly.
The date of the next review should be indicated on the Resuscitation Status
Review Sheet.
ALL REVIEWS MUST BE DOCUMENTED
Senior nurse should ensure that all nursing staff caring for the patient are
aware of the decision and that all decisions should be included in staff hand-over
briefings.
If the decision is rescinded - this is clearly recorded in the clinical notes.
The applications of DNAR decisions will be audited on a regular basis.
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