Firstly and most importantly as a CFR you must be familiar with your own Trusts policy on Do Not Resuscitate Orders.
All patients must be presumed to be “For CPR” unless a valid DNACPR decision has been made and documented or an Advance Decision to Refuse Treatment (ADRT) prohibits CPR.
The whole area of DNRs can be a minefield and there is a lot of confusion. Hopefully this will clarify a few things,
What is a DNR order?
A DNR is also known as DNAR (Do not attempt resuscitate orders), the word ‘attempt’ was probably added for grammar or legalities. To add to the list of other names for DNR order is DNACPR, used by Resuscitation Council (RCUK).
DNR means Do Not Resuscitate. It is a legal order to instruct a medical team not to perform or attempt to perform CPR on a patient.
The important thing to remember is that “DO NOT RESUSCITATE” does not mean “DO NOT TREAT”.
A DNR order on a patient’s file means it is not appropriate to resuscitate that patient if their heart stops, the order is often designed to prevent unnecessary suffering.
The usual circumstances in which it is not appropriate not to begin CPR are:
- when it is clear that it will not restart the heart or breathing
- when it is no benefit to the patient
- when the benefits are outweighed by the burdens
As a CFR you CANNOT make any clinical decisions relating to DNR CPR
There are several issues and endless scenarios but essentially if you arrive on scene and find a non-responsive, non-breathing patient and none of the above apply, then you must commence CPR unless you are presented with an official DNR order.
There is little or no point in showing a DNR order here because your Trust may have something totally different and this will cloud the issue.
Start the process now and ask your team leader, manager, training officer, CLATO etc to see a DNR and request the Trusts mandate.
If you are asked by a relative not to resuscitate – simply call your control and seek clinical advice, do not make decisions nor put yourself into a confrontational situation.
Other than DNR and DNAR, a CFR may encounter other documents that also relate to not attempting CPR.
Advance Decision to Refuse Treatment (ADRT) is a decision by an individual to refuse a particular treatment in certain circumstances. A valid and applicable ADRT is legally binding for healthcare staff. This includes CFRs
Lasting Power of Attorney (LPA) / Personal Welfare Attorney (PWA) The Mental Capacity Act (2005) allows people over the age of 18 years and over, who have capacity, to make a Lasting Power of Attorney by appointing a Personal Welfare Attorney who can make decisions regarding health and welfare – being on their behalf once capacity is lost.
Independent Mental Capacity Advocate (IMCA) An IMCA supports and represents a person who lacks capacity to make a specific decision at a specific time and who has no family or friends who are appropriate to represent them.
A Court-appointed deputy is appointed by the Court of Protection (Specialist Court for issues relating to people who lack capacity to make specific decisions) to make decisions in the best interests of those who lack capacity.
What does all this mean to the CFR?
In the event of a cardiac arrest, every attempt to resuscitate the patient should take place in accordance with the advice given by the Resuscitation Council (RCUK) unless a valid DNR decision or an appropriate ADRT or LPA is in place and made known.
A relative suggesting there is a DNR but not in possession of the document, is not sufficient to withold CPR.
The DNA order must stay with the patient, located as follows: Hospitals, Own home, nursing homes, in-patient Specialist Palliative Care setting : in the front of person’s notes,
The original DNA form must be carried with the individual on all journeys.
The legal status of those who attempt CPR 2015