CPR and DNACPR – am I following orders?
I was listening to the news on the radio a few days ago, and the newsreader said the Covid Inquiry is going to look into ‘do not attempt resuscitation orders’ - meaning cardiopulmonary resuscitation, and presumably DNACPR documentation and/or DNACPR decisions. The point of interest, is that word ‘order’.
Can ‘I’ be ordered to attempt, or to withhold, CPR?
First, I’ll consider the ‘I’ in the title of this post. I will consider three categories of individual: family-carers and relatives, ‘senior’ clinicians and ‘junior clinicians’.
Relatives and family-carers (please note that I often flip-flop between these two terms, and that ‘relative’ should be taken as inclusive of close friends, and that family-carers need not be relatives: the only real distinction is that some of these people will be more actively-involved in caring for the loved-one/patient/friend than others are), sometimes explain that a 999 call handler had ‘ordered’ them to attempt CPR. That is usually within two contexts: one is ‘the call handler ordered me to attempt CPR and I refused’ and the second amounts to ‘I attempted CPR because I was ordered to – the CPR didn’t work, and with hindsight I regret having attempted CPR’. Often the family-carer or relative knows that the loved-one would not have wanted CPR: and, you cannot have a ‘peaceful death’ if CPR is attempted. So far as I can see, our law means that a family-carer or relative CANNOT be ordered to attempt CPR, or to not attempt CPR, by anyone. And family-carers/relatives do not require a defence for not attempting CPR: there is not a ‘legal duty’ to do anything at all under our law.
In theory, it seems to me that if a family-carer is aware of an Advance Decision which refuses CPR in the circumstances of the arrest, then if the carer ignores the ADRT and does attempt CPR, then the carer could be charged with assault. But when I asked on Twitter if anyone knew of a case when a relative had been charged for attempting CPR despite knowing that an ADRT forbade CPR, nobody could point to a court case.
‘Junior clinicians’ are in a rather complex situation. There is a provision in the Mental Capacity Act, in its section 42, which [using my phrase here] ‘allows for clinicians to be ‘steered by’ their professional guidance’. You need to look at section 42 of the MCA, and section 5.31 of the original version of the MCA’s Code of Practice. The legal situation, seems to me to be hugely-complex and very challenging: and the real-world consequences of section 42 do not appear to be analysed very much by authors. The intention seems to be ‘to steer clinicians towards doing the right thing’ which is an admirable objective: but the reality is tricky to say the least! There is something of a double-edged sword here: nurses in particular, seem to be in a very problematic situation, and I believe most nurses would be very reluctant to not attempt CPR unless there is some ‘DNACPR documentation’. Unlike relatives, clinicians cannot ‘just stand back’: clinicians do need a defence against the charge of ‘you should have intervened’.
So, can those ‘junior clinicians’ be ordered to not attempt CPR? If they could, then it is obvious that senior clinicians would be ‘giving the order’. Professor Mark Taubert, a consultant in palliative care (which you can think of as a consultant in end-of-life care), would definitely be one of the people ‘giving the order’: but Professor Taubert does not believe
https://www.bmj.com/content/386/bmj-2022-071661/rr
he can write ‘a DNACPR order’. Mark explains why in the BMJ ‘Letter to the Editor’ which the above link goes to – and I agree with Mark, which is not surprising as Mark and I were co-authors of that letter.
If a welfare attorney is present during a cardiopulmonary arrest, and if the attorney has got MCA section 6(6) authority over CPR, then the attorney can forbid CPR by saying ‘I consider that attempted CPR would be against the patient’s best interests’ or ‘I consider that it is in the patient’s best interests to not attempt CPR’: which I would describe as ‘an order’. I am also happy to describe an Advance Decision, which comes from the patient, as ‘an order’.
But the documents which the NHS refers to as ‘DNACPRs’ are NOT orders.
It looks as if ‘the NHS’ would prefer it if DNACPRs could be regarded as orders – that would simplify certain situations. But contemporary DNACPR forms should not be described as ‘orders’, and I think we need to fundamentally redesign CPR documentation as I have explained at
I will be loosely following the media reports of the Covid Inquiry, and if the Inquiry itself uses the term ‘DNACPR order’ then I will probably try to send an explanation to the Inquiry, as to why ‘DNACPRs are NOT orders’.
After reading the original post, several feelings and thoughts come to mind. The complexity surrounding DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) “orders” is indeed intricate and nuanced. The post raises critical points about the language used in medical documentation and how it can lead to misunderstandings.
Ambiguity in Language: It's concerning that terms like "order" can imply a directive that isn't legally enforceable, potentially causing confusion among both relatives and healthcare professionals. The distinction between a DNACPR form and an actual binding order is crucial and should be clearly communicated to avoid any misinterpretation.
Role of Family-Carers and Relatives: The reality that family-carers and relatives can't be legally compelled to perform CPR or refrain from it highlights significant autonomy in end-of-life care decisions. However, it also underscores the importance of clear communication and legal clarity to ensure these individuals feel supported in their decisions.
Junior Clinicians' Dilemma: Junior clinicians are in a particularly challenging position. The lack of clear directives can leave them vulnerable to legal repercussions or moral dilemmas. This aspect is especially troubling as it suggests a gap in the system that needs addressing to protect healthcare workers.
Advance Decisions and Legal Authority: The post effectively argues for the necessity of Advance Decisions (ADRT) being respected as genuine orders. This not only respects the patient's autonomy but also provides a clear directive which clinicians can follow, minimizing legal and ethical confusion.
Need for Systemic Change: Overall, there seems to be a call for a systemic overhaul in how DNACPR is documented and communicated. Mark Taubert’s position in the BMJ highlights how language can impact clinical practice and patient care, reinforcing the need for clarity and precision.
For those interested in improving their understanding of CPR and emergency response, I recommend exploring the CPR course. It offers comprehensive training, enhancing one's ability to make informed decisions during critical moments.
Ultimately, this discourse invites further exploration into how we can improve the system for everyone involved, ensuring that decisions made at crucial moments are informed, compassionate, and legally sound.
Thank you Tommy.
I will be trying to contact the Covid-19 Inquiry, as this week they have been discussing DNACPR and ACP in a way which troubles me (I was pointed at the relevant video by a contact). I have no expectation that they will actually look at my communications - but all I can do is try!