Misconceptions about Cardio Pulmonary Resuscitation (CPR) and 'Do Not Attempt Resuscitation' (DNAR) orders may have contributed to recent controversy in this area. CPR is the broad description for a series of invasive interventions administered when someone suffers sudden cardiac or respiratory arrest, so as to restart their heart or breathing and restore their circulation.
General Medical Council (GMC) guidance summarises:
"CPR interventions are invasive and include chest compressions, electric shock by an external or implanted defibrillator, injection of drugs and ventilation. If attempted promptly, CPR has a reasonable success rate in some circumstances. Generally, however, CPR has a very low success rate and the burdens and risks of CPR include harmful side effects such as rib fracture and damage to internal organs; adverse clinical outcomes such as hypoxic brain damage; and other consequences for the patient such as increased physical disability. If the use of CPR is not successful in restarting the heart or breathing, and in restoring circulation, it may mean that the patient dies in an undignified and traumatic manner."
As indicated above, despite the best efforts of medical staff, CPR does not have a good success rate. With CPR performed in hospitals, only one in five people survive and even when successful, a person can often develop serious and sometimes painful complications including fractured ribs, damage to the liver and spleen and brain damage leading to disability. Many people who do survive then require admission and prolonged treatment in an intensive care unit, where they may die anyway.
Due to the low success rate and the corresponding high risk of complications, many people, especially those with terminal illnesses, make it clear to their medical team that they do not want to be treated with CPR in the event of respiratory or cardiac arrest. Following such a decision a DNAR order should be placed within the patient’s medical records to inform the treating clinical team. If a patient has a serious illness or is undergoing surgery that could cause respiratory or cardiac arrest, a member of the medical team should consider the merits of a DNAR order in advance.
The law on DNAR
The Court of Appeal in R (Burke) v General Medical Council (Official Solicitor and others intervening)  confirmed that: "once a patient is accepted into a hospital, the medical staff come under a positive duty at common law to care for the patient" and that a "fundamental aspect of this positive duty of care is a duty to take such steps as are reasonable to keep the patient alive".
However, the Court of Appeal also confirmed in Burke that if a patient "wants a form of treatment which the doctor has not offered him, the doctor will, no doubt, discuss that form of treatment with him (assuming that it is a form of treatment known to him) but if the doctor concludes that this treatment is not clinically indicated he is not required (i.e. he is under no legal obligation) to provide it to the patient although he should offer to arrange a second opinion".
CPR is a treatment and accordingly, the decision to impose a DNAR order is a clinical one, otherwise a patient would be able to impose upon a doctor an obligation to carry out treatment in the form of CPR, which the doctor may not countenance providing he could not say that it was clinically justified.
Guidance has been provided by the GMC and the British Medical Association in conjunction with the Resuscitation Council (UK) and the Royal College of Nursing on the requirements for consultation with a patient prior to imposition of a DNAR order.
GMC Guidance makes it clear that there is a distinction between the imposition of a DNAR order where, in the opinion of the clinicians, CPR would be unsuccessful and where CPR may be successful, but that the benefits of prolonging life are outweighed by the potential burdens and risks.
Consultation in the former situation is limited to informing the patient that the DNAR decision has been made:
"If a patient is at foreseeable risk of cardiac or respiratory arrest and you judge that CPR should not be attempted, because it will not be successful in restarting the patient’s heart and breathing and restoring circulation, you must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made. You should not make assumptions about a patient’s wishes, but should explore in a sensitive way how willing they might be to know about a DNACPR decision. While some patients may want to be told, others may find discussion about interventions that would not be clinically appropriate burdensome and of little or no value. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team. If you conclude that the patient does not wish to know about or discuss a DNACPR decision, you should seek their agreement to share with those close to them, with carers and with others, the information they may need to know in order to support the patient’s treatment and care."
In reaching the decision to impose a DNACPR notice on the basis that it is not in the patient’s best interests that CPR be attempted, good medical practice requires the relevant clinicians to consult with those properly concerned including, if at all possible, the patient themselves and/or those identified by the patient as persons whom they wish to be involved in the discussions. In such discussions, the views of a patient with capacity should carry significant weight, even if they cannot be determinative.
In either of the situations in which consideration is being given to the imposition of a DNACPR notice, then in the event of a disagreement between patient (or the family or proxy of a patient in the event that the patient lacks capacity and/or has indicated that she wishes their views to be taken into account) and the healthcare team as to whether CPR should be provided, good medical practice suggests that consideration is given to a second opinion being sought.
Some might argue DNAR denies a patient the opportunity to receive live-saving treatment. However, given the success rate of CPR treatment is often so low and the risks of complications are so high it is clear the decision to impose a DNAR order must remain a clinical one. There are however clear obligations upon treating clinicians to record and reflect upon their consideration of the benefits of this treatment and the patient’s wishes.