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ROYAL BERKSHIRE AMBULANCE
NHS TRUST
OP /
OPERATIONAL POLICY & PROCEDURE
DECISIONS RELATING TO
CARDIOPULMONARY RESUSCITATION
Introduction
Cardiopulmonary Resuscitation (CPR) can be attempted on any individual in whom cardiac or
respiratory function ceases. Failure of these functions is inevitable as part of dying and thus
CPR can theoretically be used on every individual prior to death. It is therefore essential to
identify patients for whom cardiopulmonary arrest represents a terminal event in their illness
and in whom CPR is inappropriate. It is also vital to encourage the involvement of patients,
the health care team and people close to the patient in decision making, and to ensure the
communication of decisions to all relevant health professionals.
Background
"Do-not-attempt-resuscitation" (DNAR) decisions may be a potent source of misunderstanding
and dissent amongst clinicians and others involved in care of patients. The factors surrounding
a decision whether or not to initiate CPR involve complex clinical considerations and
emotional issues. The decision arrived at in the care of one patient may be inappropriate in a
superficially similar case. Many of the problems in this difficult area would be avoided if
communication and explanation of the decision were improved, both to relevant health
professionals and people close to the patient.
Unfortunately, in many cases, staff least experienced or equipped to undertake such sensitive
tasks carries out the resuscitation of a patient. A letter from the Chief Medical Officer
(PL/CMO (91) 22) following a case brought to the attention of the Health Service
Commissioner clarified where responsibility lies. The Chief Medical Officer makes it clear
that the responsibility for resuscitation policy lies with the consultant concerned and that each
consultant should ensure that this policy is understood by all staff who may be involved.
Guidelines
1. It is appropriate to consider a do-not-attempt-resuscitation (DNAR) decision in the
following circumstances:
a) Where the patient's condition indicates that effective cardiopulmonary resuscitation
(CPR) is unlikely to be successful. See Adult Death Policy.
b) Where CPR is not in accord with the recorded, sustained wishes of the patient who
is mentally competent. Such discussions, and any anticipatory decisions, should be
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documented, signed and dated, in the patient's record. Negotiations are taking place
with Health Authority, Acute Care Trusts and Primary Care Trusts regarding
access to this information by the Royal Berkshire Ambulance NHS Trust. NB.
Indications so far are that the patient / carer should hold a letter from the consultant
involved in the current episode of patient care, stating that CPR should not be
initiated
c) Where CPR is not in accord with a valid applicable advance directive (anticipatory
refusal or living will). A patient's informed and competently made refusal which
relates to the circumstances that have arisen is legally binding upon clinicians. Clear
evidence of this must be given to ambulance staff at the scene.
d) Where successful CPR is likely to be followed by a length and quality of life which
would not be in the best interests of the patient to sustain. This can only be
ascertained in the presence of a medical doctor, who has had appropriate
discussions with the patient and/or carer and must sign the statement "Not for
CPR" in the "Comments" box of the Patient Report Form (PRF).
2. The entry on the PRF of the decision not to resuscitate and reasons for it should be
made by the most senior clinician available (eg GP or Paramedic, etc). This person
should ensure that the decision is effectively communicated to other clinicians
involved in the care of the patient eg GPs, receiving hospital, etc. by protocolled use
of the PRF.
3. Where a DNAR decision has not been made and the express wishes of the patient
are unknown, resuscitation should be initiated if cardiac or respiratory arrest
occurs. Anyone initiating CPR in such circumstances will be supported by their senior
colleagues
4. Relatives and others close to the patient cannot determine a patient's best interests, nor
give consent or refuse treatment on a patient's behalf.
5. A DNAR decision applies solely to CPR. It should be made clear that all other
treatment and care, which are appropriate for the patient, are not precluded and should
not be influenced by a DNAR decision. To avoid all confusion, the expression "not
for cardiopulmonary resuscitation" should be used and included in the patient's notes /
on the PRF.
6. Experience with DNAR decisions is an appropriate subject for clinical audit.
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Royal Berkshire Ambulance Trust Reference:
Clinical Effectiveness\Policies\Emergency Services\Cardiopulmonary Resuscitation (3 pages)
(TO BE CHANGED WHEN FINAL TO CHIEF EXECUTIVE FILES)
Controlled document: CEf 40 CE/xx
February 2001
Revision 0
Review date January 2003
Revision 0
This document is based on a Joint Statement from the British Medical Association, the Resuscitation
Council (UK) and the Royal College of Nursing
Medical Ethics Department
British Medical Association
BMA House
Tavistock Square
London WC1H 9JP
Telephone: 020 7383 6286
Fax: 020 7383 6233
Email: ETHICS@bma.org.uk
Other Published Guidance



Ethical Decision-Making in Palliative Care: Cardiopulmonary
Resuscitation (CPR) for People who are Terminally Ill.
Joint Working Party between the National Council for Hospice and
Specialist Palliative Care Services and the Ethics Committee of the
Association for Palliative Medicine of Great Britain and Ireland
(undated)
The 1998 Resuscitation Guidelines for use in the United Kingdom.
Resuscitation Council (UK), June 1998
Resuscitation of Babies at Birth.
Royal College of Paediatrics and Child Health,
Royal College of Obstetricians and Gynaecologists,
BMJ Publishing Group 1997
Acknowledgements
Written by:
C Breen
Clinical Effectiveness Officer
Approved by:
S Brown
Medical Director
At Clinical Effectiveness Meeting
8/1/02
Accepted by:
Debbie Dunning
Emergency Services Director
At Operations Committee
12/1/02
Accepted by:
Ken Sealy
Non-Executive and Chairperson
At Risk and Clinical Governance Meeting
22/1/02
Accepted by:
Keith Nuttall
Chief Executive, Royal Berkshire Ambulance NHS Trust
At Board Meeting:
TBA
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