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Flashcards in Decisions in Resus Deck (15):

Advance decision

The term ‘advance decision’ may apply to any expression of patient preferences. Refusal does not have to be in writing in order to be valid. If patients have expressed clear and consistent refusal verbally, this is likely to have the same status as a written advance decision.

People should ensure that their healthcare team and those close to them are aware of their wishes.

In sudden out-of-hospital cardiac arrest, those attending usually do not know the patient’s situation and wishes and, even if an advance decision has been recorded, it may not be available. In these circumstances CPR can be started immediately and any further information obtained when possible.

There is no ethical difficulty in stopping a resuscitation attempt that has started if the healthcare professionals are presented later with a valid advance decision refusing the treatment that has been started.


Advance Decision to Refuse Treatment

With people who wish to refuse treatment that is potentially life-sustaining, for example ventilation, special rules apply. Their advance decision must be in writing, signed and witnessed.

This document will outline in which specific circumstances the person does not want potentially life sustaining treatment. It can be legally binding if all the specific circumstances that have been identified have been met.

Resuscitation must not be attempted if CPR is contrary to the recorded, sustained wishes of an adult who had capacity and was aware of the implications at the time of making that advance decision.


Do not attempt resuscitation and
Do not attempt cardiopulmonary resuscitation

Unfortunately some healthcare providers have mistakenly and inappropriately interpreted the recording of DNAR decisions as indicating that other treatment can or should be withheld. To discourage this it has been suggested that the term DNACPR should be used, to try to emphasise that the recorded decision refers only to the use of CPR and not to any other aspect of treatment that the patient may need.

Do not attempt resuscitation (DNAR) means that in the event of cardiac or respiratory arrest, CPR should not be started - nothing more than that. Other treatment should be continued, including pain relief and sedation, as required. Treatment such as ventilation and oxygen therapy, nutrition, antibiotics, fluid and vasopressors is also continued as indicated. If not, orders not to continue or initiate any such treatments should be made independently of DNAR orders.



Futility may be considered to exist if resuscitation will not prolong life of a quality that would be acceptable to the patient. Medical futility is the main reason for a DNAR decision.

The overall responsibility for a DNAR decision rests with the senior healthcare professional in charge of the patient, after appropriate consultation with other healthcare professionals involved in the patient’s care. This type of decision is often complex and should be undertaken by senior, experienced members of the medical team.


Involving patients

People have ethical and legal rights to be involved in decisions that relate to them and if the patient has capacity their views should be sought unless there is a clearly justifiable reason to indicate otherwise.

It is not necessary to initiate discussion about CPR with every patient, for example if there is no reason to expect cardiac arrest to occur, or if the patient is in the final stage of an irreversible illness in which CPR would be inappropriate as it would offer no benefit.


Involving relatives

It is good practice to involve relatives in decisions although they have no legal status in terms of actual decision-making.

A patient with capacity should give their consent before involving the family in a DNAR discussion. Refusal from a patient with capacity to allow information to be disclosed to relatives must be respected.


Lack of capacity

If patients who lack capacity have previously appointed a welfare attorney with power to make such decisions on their behalf, that person must be consulted when a decision has to be made balancing the risks and burdens of CPR.

The Mental Capacity Act 2005, which applies in England and Wales requires appointment of an Independent Mental Capacity Advocate (IMCA) to act on behalf of the patient who lacks capacity. However, when decisions have to be made in an emergency, there may not be time to appoint and contact an IMCA and decisions must be made in the patient’s best interests, and the basis for such decisions documented clearly and fully.


Grey areas

Inevitably, judgments will have to be made, and there will be grey areas where subjective opinions are required in patients with comorbidity such as heart failure, chronic respiratory disease, asphyxia, major trauma, head injury and neurological disease.

The age of the patient may feature in the decision but is only a relatively weak independent predictor of outcome; however, the elderly commonly have significant comorbidity, which influences outcome.

When differences of opinion occur between the healthcare team and the patient or their representatives these can usually be resolved with careful discussion and explanation, or if necessary by obtaining a second clinical opinion.


Stopping resus

The decision to stop CPR can be made when it is clear that continuing CPR will not be successful.

In general, CPR should be continued as long as a shockable rhythm or other reversible cause for cardiac arrest persists. It is generally accepted that asystole for more than 20 minutes in the absence of a reversible cause, and with all advanced life support measures in place, is unlikely to respond to further CPR and is a reasonable basis for stopping CPR.

In out-of-hospital cardiac arrest, CPR will be started unless:

There is a valid advance decision refusing it, or
A valid DNAR order, or
It is clear that CPR would be futile


A colleague states that she does not want to be resuscitated if she ever has a cardiac arrest. The next week she sustains a cardiac arrest in front of you.

Yes, you should start resuscitation.

A comment of this nature may have been made out of context, or without thought for the full implications.

In the absence of an ‘Advanced Directive’ or a documented and valid DNAR order, resuscitation should always be commenced under such circumstances.


A colleague states that she does not want to be resuscitated if she ever has a cardiac arrest. The next week she sustains a cardiac arrest in front of you.

You find out that she was diagnosed last week with cancer and is taking anti-depressants.

Yes, you should continue resuscitation.

In the absence of a legally binding ‘Advanced Directive’ or DNAR order resuscitation should be continued.

We do not know the extent of the cancer in this case and how much treatment is available.

Anti-depressants imply a state of mind that may affect the patient’s capacity to make an informed decision.


A colleague states that she does not want to be resuscitated if she ever has a cardiac arrest. The next week she sustains a cardiac arrest in front of you.

Her partner arrives and asks you to reverse your decision.

You should continue resuscitation, at least initially.
Whilst it is good practice to involve relatives in decisions, the legal decision to stop CPR in England and Wales cannot be made by a relative alone.

The decision to stop resuscitation should be made by the most senior clinician involved in the patient’s care, usually after discussion with the family and other healthcare staff who know the patient. The partner’s views would be taken into consideration, but the decision would be made with the patient’s best interests in mind.

The exception is when a patient has appointed a personal legal representative to make decisions on their behalf if the patient lacks mental capacity. If this is the case, the partner can verify his authority.


An 82-year-old woman falls and sustains a fractured neck of femur. She lives in sheltered housing, is prone to forgetfulness and has been unwell for the last 2 days. A resuscitation decision needs to be made. A decision to withhold CPR generally involves a number of people. Who should be involved with this decision?

The doctor in charge of the patient’s care carries the legal responsibility for a DNAR decision.

The decisions for a DNAR order can be made on the grounds of:

Futility (negligible chance of success), or
The treatment not being in the patient’s best interest, or
A response to a request from the patient or their legally appointed guardian that they do not wish to be resuscitated
The decision should not be made in isolation and should be clearly documented in the patient’s medical notes. The DNAR order should be regularly reviewed, especially if there is any change in the patient’s condition.

Nurses involved in the patient’s care should be consulted when making a DNAR decisions.

Nurses often provide valuable insight into what is in the patient’s best interest.

Patients’ relatives should be involved whenever possible if a DNAR order is being considered. If the patient is unable to make decisions due to mental incapacity, the Mental Capacity Act requires clinicians to involve relatives or people close to the patient in treatment limitation decisions.

The patient may also have appointed someone to be a personal legal representative in the event of mental incapacity. This representative must be registered with the authorities and always act in the patient’s best interest.

If a doctor considers treatment to be futile, relatives cannot force treatment. However conflict with relatives should be avoided wherever possible. A sensitive discussion about what the process of resuscitation involves will often alleviate concerns, as will assurance that all other relevant treatment and care will continue.

The patient with mental capacity should be central to the DNAR decision making process.

The resuscitation process, risks and benefits should be explained to the patient and their view sought. The exception is where the doctor considers that to offer resuscitation is futile. In this situation, the doctor should sensitively explain the reasons for the decision.

Problems relating to resuscitation decisions most commonly arise from a failure of healthcare staff to communicate effectively with the patient and relatives.


Assistance in a public place

The law in the UK is unusual in that there is no legal obligation to provide assistance in a public place. This is not the case in most of Europe, where doctors have a legal responsibility to provide care.

If the decision is made to stop and provide help, then the legal situation changes however. Once help is offered the healthcare professional now assumes a ‘Duty of Care’ and by implication a ‘Standard of Care’ is then expected, compatible with that healthcare individual’s professional status.

There have been no cases of successful litigation against healthcare professionals who have acted in a ‘Good Samaritan’ capacity.


The Ambulance Service arrives and, on monitoring, he is found to be asystolic and remains in this rhythm. Should resuscitation be continued?

The Ambulance Service arrives and, on monitoring, he is found to be asystolic and remains in this rhythm. Should resuscitation be continued?

Deciding when to stop a resuscitation attempt outside hospital is very difficult and most healthcare staff would probably not do so until arrival of the victim at hospital where a senior clinician can make the decision.

It is reasonable however, under certain circumstances, to abandon resuscitation attempts and occasionally not even begin.

Ambulance staff have clear guidance on this and when rigor mortis, body decomposition or injuries incompatible with life have occurred e.g. decapitation, then clearly resuscitation attempts need not be made.

In other circumstances when CPR has been commenced, the decision to stop can be made by those who feel experienced enough to do so. Asystole for greater than 20 minutes is associated with such a poor outcome that most clinicians would stop CPR under these circumstances in a prehospital setting.