The decision not to institute CPR if it is likely to be successful should not be taken lightly, or in isolation. If the patient is competent, he or she should be involved in the decision making, as should the family (with the patient’s consent). Ideally, the whole healthcare team should also be consulted.
Ultimately, though, the decision rests with the senior clinician in charge of the patient’s care.23
Such decisions should not be made on the basis of assumptions about the patient’s age, condition or perceived quality of life, but on a clinical assessment of the potential benefits and burdens of resuscitation on the individual, taking into account what is known about the patient’s views, beliefs and wishes and those of his or her close relatives (see Box 8).
If a DNR order is made, this should be clearly documented in the patient’s notes, together with the reasons for the decision and the process of decision making.24
Box 8: DNR decisions
“A decision that CPR will not be attempted, on best interests grounds, because the burdens outweigh the benefits should be made only after careful consideration of all relevant factors, discussion with the patient, or those close to patients who lack capacity, and these include:
- the likely clinical outcome, including the likelihood of successfully restarting the patient’s heart and breathing for a sustained period, and the level of recovery that can realistically be expected after successful CPR
- the patient’s known or ascertainable wishes, including information about previously expressed views, feelings, beliefs and values
- the patient’s human rights, including the right to life and the right to be free from degrading treatment
- the likelihood of the patient experiencing severe unmanageable pain or suffering
- the level of awareness the patient has of their existence and surroundings.”
Source: British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing, Decisions Relating to Cardiopulmonary Resuscitation: A Joint Statement (2007), p. 11.