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Home Elderly Care Home Care DNRs – Do Not Resuscitate Orders: what you need to know about them

DNRs – Do Not Resuscitate Orders: what you need to know about them

A “Do Not Resuscitate” order is signed and given by a Doctor to prevent the specific medical intervention of CPR for a patient who has suffered a heart attack or stopped breathing.  For older people it may be used where the treatment would either not achieve its purpose or where it may have negative consequences. This Guide to DNR orders explains the terminology, what a DNR actually means, when it may be used.  

Why is a DNR/DNACPR Important?

A DNR order sounds brutal – the decision not to give CPR to an individual, however it has the best interests of the patient at heart. 

DNARs - what you need to know

A person can request a DNR order themselves at any time whether or not they need treatment at that time.  To make a DNR legally binding in the future it should be included in a Lasting Power of Attorney and/or an Advance Decision.

A Doctor can and should where appropriately discuss and agree to a DNR in consultation with their patient.  A Doctor can also decide that a DNR is the best course of action without the consent of the patient or their family if necessary.    

DNR and CPR

A DNR (or DNACPR, DNAR as it is also known) only applies to CPR in the case of a heart attack or if someone stops breathing.  Other treatment and care will continue to be administered.

What is CPR?

CPR stands for cardiopulmonary resuscitation. It’s a treatment that can be given when someone stops breathing (respiratory arrest) or their heart stops beating (cardiac arrest).  CPR tries to get the breathing and heart going again. It can involve:

  • pressing down hard on the chest repeatedly (chest compressions)
  • a machine to stimulate your heart using electrical shocks (sometimes more than once)
  • equipment that helps move oxygen around your body (artificial ventilation)
  • giving medicine by injection

Why is CPR not always considered to be appropriate?

The actions used in CPR, such as chest compressions, can cause bruising, break ribs, and puncture lungs.

Only a few people make a full recovery even if their heart or breathing can be restarted with CPR.

What is CPR?

They may still be very unwell and need more treatment and they may never get back to the health they had before.

The heart and/or brain may be permanently damaged. This is why DNACPR forms are written. They mean someone does not receive a treatment that may prolong or cause suffering at the end of their life.

How is a DNR recorded and Kept?

A DNACPR decision is made by the individual concerned and/or their doctor or healthcare team and is usually recorded on a special form. Different forms may be used but they all serve the same purpose. Some examples are a DNACPR form, a treatment escalation plan, or a ReSPECT form (recommended summary plan for emergency care and treatment process).

Whichever type of form, it should be kept with the person’s medical records, and a hard copy available and accessible (kept maybe with a list of medication) where the individual lives – at home or in a care home –  in case the situation arises where it may be necessary. The form says that if your heart or breathing stops, CPR should not be tried. This means medical staff will not try to restart your heart or breathing.

An individual should know that a DNACPR form has been put in their medical records, but there is no obligation to tell relatives.

When is a DNACPR decision made, and who makes it?

When an individual decides in advance to refuse CPR

Everyone can refuse CPR by putting in place a DNR if they wish. This decision can be made at any time, when they are healthy or when they are approaching the end of their life.

If someone wishes to make their refusal of CPR legally binding for the future if they are unable to make this decision, then they should write an Advance Decision to refuse treatment. https://www.agespace.org/legal/living-wills

Anyone can change their mind about their DNACPR decision but will need to tell the doctors and nurses so that the DNACPR form is marked as no longer valid.

When a Doctor decides on a DNR without patient consent

DNACPR is a medical treatment decision that can be made by a doctor even if the patient does not agree to it. The patient must be told that a DNACPR form will be/has been completed for them, but a doctor does not need the patient’s consent.

Doctors can only not tell someone that a DNACPR form has been completed for them if they think doing so would cause physical or psychological harm.

The patient should be given the chance to understand what a DNACPR is, how the decision is made and why they think CPR would not be suitable for them. For example, the doctor may think that CPR will not help the person live longer, or that giving them CPR could cause them more harm. This may be because organs are already too damaged because of another illness, or the person is approaching the end of their life. The doctor makes the final decision.

A word about DNRs during the pandemic

There was some concern during the pandemic about the use of DNACPRs in care homes and in hospitals.  For clarity sake, a DNACPR decision must be made on an individual (person by person) basis. This means it must be based on health, needs, and priorities as an individual. The judgement about whether the discussion or decision would cause the patient harm should also be made on an individual basis.

DNACPR decisions should not be made for a group of people at once. For example, DNACPR decisions should not be made for everyone living in a care home or for a group of people over a certain age. This is unlawful, irrespective of medical condition, age, disability, race, or language.

When someone can no longer make their own decisions

If someone has been assessed as unable to make a decision for themself, they will be referred to as “lacking capacity”.  

DNACPR what you need to know

Concern about a DNACPR

In this situation doctors should check if they have an Advance Decision (ADRT) or a Lasting Power of Attorney in place for health and care decisions https://www.agespace.org/legal/power-of-attorney

If someone wants their LPA to make decisions about CPR, then they must complete and sign a particular section on life-sustaining treatment in the LPA document. This will mean that their attorney can make the decision relating to CPR in their best interests. The attorney cannot insist on CPR being given.

If someone does not have an Advance Decision ADRT (which says that you do not want CPR) or an LPA (with life-sustaining treatment decision-making powers) then a best interests decision is made by the senior doctor.

If you are concerned about a DNACPR form on record for yourself or someone else, raise your concerns with your doctor. If you are still not happy, then you can ask for another doctor’s opinion.

No-one can demand CPR. The law does provide the right to be involved in and informed of a doctor’s DNACPR decision but does not require the Doctor to get  consent to a DNACPR.

If the patient has capacity to make their own decisions they will need to agree to it being discussed with someone else such as you. For someone who does not have capacity, those with the legal power to represent them can raise concerns on their behalf.

Complaining about a DNACPR/DNR

No-one has the right to demand CPR so the decision to put in place a DNR may not change if there was a good clinical reason for it. The doctor should explain the reasons and ask about the patient’s wishes and preferences.

GP Surgery Complaints process

If the DNACPR form was made by a GP, and you are not happy with their response, you should follow the practice’s complaints procedure. If you are still concerned, or you wish to make a complaint, contact NHS England and NHS Improvement.

NHS Hospital complaints process

If the DNACPR form was made by a doctor in a hospital, and you are not happy with their response, you can ask to speak to the senior doctor on duty or the consultant responsible for your care. The hospital should have its own complaints procedure. This will tell you how to make a complaint.

Consumer complaints process

If your DNACPR form was made by a GP or doctor in a hospital, you can contact your local Healthwatch to find out about how to get help making a complaint. You can also have support from an advocate if you want help to make a complaint about your GP or a doctor in the hospital.

If you are still not happy with the response you can contact the Parliamentary and Health Service Ombudsman.

What is a ReSPECT Plan?

ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. This system is used in many, but not all areas of the UK. Your healthcare team will explain if they use it.  The plan includes information about you and your health. It explains:

  • what is important to you
  • your preferences for care in an emergency

It also explains what your healthcare team think is best for you. This includes whether or not CPR should be given if your heart and breathing stop.

The plan is made with you by your healthcare team.

If ReSPECT has not been established in your locality, but you would like to take steps now to ensure what is important to you is known about, then you could make an Advance Decision to Refuse Treatment (ADRT).

Many parts of England and Scotland have now adopted the ReSPECT process, while Northern Ireland and Wales are yet to adopt ReSPECT.  Check this data to find out if it’s been adopted where you live.