Guidance to support resuscitation decisions

27 November 2007

The British Medical Association, the Royal College of Nursing and the Resuscitation Council (UK) have issued new guidance to support decisions about resuscitation attempts in patients who have stopped breathing or whose heart has stopped.

The guidance emphasises the importance of healthcare professionals being open and transparent about decisions about cardiopulmonary resuscitation (CPR). The guidelines identify the key ethical and legal issues that should inform all CPR decisions and provide a framework to support these decisions and communicate them effectively.

There are significant differences between the new and preceding guidance including:

The Mental Capacity Act included to cover decision-making for patients who lack capacity and guidance on who needs to be involved.
A clearer distinction between decisions based solely on clinical factors and those based on a balance of benefits and burdens.
The need for local policies that ensure good communication between hospitals, the ambulance service and primary care.
Clearer guidance provided on who can make decisions about CPR. Suitably experienced nurses may make decisions if local policy allows; previously only consultants and GPs were able to make decisions about CPR.

Some of the main messages arising from the guidance include:

Decisions about CPR must be made on the basis of an individual assessment of each patient’s case.
Advance care planning, including making decisions about CPR, is an important part of good clinical care for those at risk of cardiorespiratory arrest.
It is not necessary to initiate discussion about CPR with a patient if there is no reason to believe that the patient is likely to suffer a cardiorespiratory arrest.
Where no explicit decision has been made in advance there should be an initial presumption in favour of CPR.
If CPR would not re-start the heart and breathing, it should not be attempted.
Where the expected benefit of attempted CPR may be outweighed by the burdens, the patient’s informed views are of paramount importance. If the patient lacks capacity those close to the patient should be involved in discussions.
If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable advance decision refusing CPR, this should be respected.
A do not attempt resusitation (DNAR) decision does not override clinical judgment in the unlikely event of a reversible cause of the patient’s respiratory or cardiac arrest that does not match the circumstances envisaged.

The full guidance is available on the Resuscitation Council website at www.resus.org.uk/pages/dnar.pdf