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Analysis

Resuscitation policy should focus on the patient, not the decision

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j813 (Published 28 February 2017) Cite this as: BMJ 2017;356:j813
  1. Zoë Fritz, Wellcome fellow in society and ethics and consultant in acute medicine12,
  2. Anne-Marie Slowther, reader in clinical ethics1,
  3. Gavin D Perkins, professor of critical care medicine13
  1. 1Warwick Medical School, Division of Health Sciences, Gibbet Hill Campus, Coventry CV4 7AL, UK
  2. 2Cambridge University Hospitals
  3. 3Heart of England NHS Foundation Trust, University of Warwick
  1. Correspondence to: zoe.fritz{at}addenbrookes.nhs.uk
  2. Accepted 13 February 2017

Zoë Fritz and colleagues discuss new approaches to resuscitation decisions that incorporate broader goals of care

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions are made commonly in healthcare but can be a source of ethical concern and legal challenge. They differ from other healthcare decisions because they are made in anticipation of a future event and concern withholding, rather than giving, a treatment. DNACPR decisions were introduced to protect patients from invasive treatments that had little or no chance of success. However, inconsistencies in decision making, communication, and documentation have led to misunderstandings about what DNACPR means and to delivery of poorer care to some patients. Here we discuss the problems with current practice and outline newer approaches that place the patient, and their family, at the centre of the discussions. We focus on overall treatment plans and supporting clinicians and patients to make shared decisions about emergency treatments.

DNACPR decisions

CPR is an invasive medical treatment that was never intended to be given to patients who are dying from an irreversible condition.1 DNACPR decisions provide a way of communicating when patients should not receive CPR, either because they do not want it or because it has little chance of success (box 1). They are an important mechanism for protecting patients from harm, but they have taken on practical, legal, and emotional significance far beyond their intended remit.6

Box 1: Clinical context of CPR and DNACPR

  • DNACPR decisions are considered in three situations:

    • when a patient with capacity refuses CPR or a patient without capacity has recorded their refusal of CPR in advance

    • when CPR is judged very unlikely to be effective because the patient is dying from an irreversible condition

    • when the potential burdens of CPR outweigh the potential benefits

  • DNACPR policies are in widespread use. They exist in many countries,2 and 80-90% of those who …

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