QuestionSBA
QuestionChoice
This is not necessary as there has been a clear formal discussion with the patient whilst she had capacity where she made her wishes clear.
31907
e
Discuss with the hospital legal department
QuestionChoice
The next of kin has no role in decision making about resuscitation. It is good practice to discuss resuscitation decisions with the next of kin; however, it is ultimately the patient and/or medical practitioner who decides, depending on the circumstances
31904
b
Consider DNACPR based on wishes of next of kin
QuestionChoice
This patient should not be for resuscitation as there is a previously documented discussion where she has refused. It can be re-discussed if she regains capacity and can hold this conversation.
31906
d
Leave for resuscitation until she is awake enough to have a formal discussion
QuestionChoice
As this patient clearly stated that they would not like to be resuscitated whilst she had capacity, a DNACPR form should be instigated. It it important to take into consideration the patient's prior wishes when considering DNACPR forms. 
31903
a
Complete DNACPR form
QuestionChoice
This patient should not be for resuscitation as ultimately patients have a right to refuse resuscitation as long as they have capacity. When this patient discussed resuscitation, she did have capacity.
31905
c
Document that this patient is for resuscitation
QuestionComment
Is the documented discussion enough to retrospectively fill out a DNACPR form? 
7926
User
subscriber
Serotonin Relapse
QuestionComment
i thought that in-hospital DNACPR forms were only valid for that hospital admission and had to be reassessed and rewritten on each admission? If she'd changed her mind etc. wouldn't it be better to ask loved ones until she's able to communicate herself?
8415
QuestionComment
Agreed, each DNACPR form can either be written for that specific hospital admission or with no-end date. NHS website says "It's recommended that a DNACPR is reviewed each time your situation changes – for example, when you leave hospital."
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User
subscriber
Gland Hereditary
User
subscriber
Lateral Biopsy
Concept
Chapter
# Overview

A Do Not Attempt CPR (DNACPR) decision can also be known as Do Not Attempt Resuscitation (DNAR)

A DNACPR decision provides information to healthcare professionals present on the best action to take if an individual suffers a cardiac arrest. A DNACPR is recorded, normally on a CPR Decision form, but is not in itself legally binding. This means that a doctor can overrule an existing DNACPR if they believe the circumstances do mean CPR would be in the patient's best interests.

A DNACPR can be made if cardiac or respiratory arrest is an expected part of the dying process, and either CPR will not be successful, or if CPR may be successful but the clinical outcomes (e.g. trauma and prognosis) mean it is not clinically appropriate. A patient with capacity may also refuse CPR.

# Best Interests 

Doctors can ultimately make the decision to put a DNACPR in place if it is in the patient's _best interests_, even if the patient themselves or their family disagrees. However, following a legal case in 2014, doctors must engage the patient and those close to them on the decision to make a DNACPR, and inform them if the decision to make a DNACPR order has occurred.

# R (Tracey) v Cambridge University Hospitals NHS Foundation Trust, 2014 

Janet Tracey died in Addenbrooke's Hospital in March 2011. She had been diagnosed with terminal lung cancer and had subsequently been involved in a car crash, in which she sustained a spinal injury. She required ventilation in the Intensive Care Unit (ICU), and after attempts to remove her from the ventilator were unsuccessful, a DNACPR notice was placed in her medical notes. Neither Janet Tracey nor her family were consulted about or informed of this decision.

The legal case concluded in favour of Tracey, finding that her Human Rights had been breached. The case acknowledged that the decision to put a DNACPR in place is ultimately a medical decision, and patients cannot demand treatment. But, the case did result in changes to DNACPR guidance:

Firstly, the decision to not tell a patient about a DNACPR notice can no longer be based on the fact that telling them would cause “distress”. Only if discussing a DNACPR order would cause the patient “physical or psychological harm”, can doctors justify not discussing it. In other circumstances, doctors are legally obliged to discuss a DNACPR order that has been made.

Secondly, it used to be the case that doctors were not obliged to discuss a DNACPR decision if the clinical decision has been made that CPR would be futile. This case amended this, making it a legal obligation for doctors to inform the patient that a DNACPR decision has been made, regardless of whether or not CPR could ever be successful (i.e. futility of CPR is justification for doctors making a best interests decision to make a DNACPR order - even if the patient wants CPR, but doctors are still legally obliged to inform the patient that a DNACPR order has been made).

A DNACPR decision relates only to CPR, and is not a refusal of any other treatment.
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DNACPR decisions
Topic
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Ethics and Law
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Respecting a patient's previously expressed wishes regarding resuscitation is crucial when determining the appropriateness of a DNACPR order.
A 90-year-old is admitted to hospital from a care home with a two day history of dysuria, urinary incontinence and increased confusion. She is pyrexial and extremely drowsy and is unable to hold a conversation. She has a background of congestive heart failure, hypertension, dementia and recurrent urinary tract infection. On her electronic patient record, there is a discussion documented from an admission with a fall three months ago where she states that she would not like to be resuscitated in the event of a cardiac arrest. It was documented by the team at the time that she had capacity. 

Which of the following is the next best step?
a