Do Not Attempt Cardiopulminary Resuscitation (DNACPR)

Cardiopulmonary resuscitation (CPR) is a treatment that could be attempted on any individual in whom cardiac or respiratory function stops. Such events are inevitable as part of dying and thus, theoretically, CPR could be given to every patient when they die. It is therefore essential to identify patients for whom cardiopulmonary arrest represents the terminal event in their illness and for whom CPR would be inappropriate because it will not work and/or is not wanted by the patient.

The aim of CPR is to restore spontaneous breathing and circulation in a way that is sustainable for that patient. As with any treatment, CPR should only be offered if there is a clear expectation that its aim can be achieved.

Where it is clear that CPR would not be successful (i.e. would not achieve sustainable spontaneous breathing and circulation) it should not be offered. There is a common lay-public misconception, possibly fuelled by media coverage, that CPR is always a potential life-saving treatment and that patients always have the right to be offered this treatment. Where it is clear in advance that CPR would not be successful it is essential that the information that CPR cannot be offered is clearly and sensitively shared with patients unless it is judged that the conversation would cause physical or psychological harm. Where a patient lacks capacity to engage with this conversation relatives/relevant others (those close to the patient) must be informed without delay where that is practicable and appropriate. A clinical decision that CPR will not work should be sensitively explained as part of a wider person-centred conversation about the patient’s goals of care in the context of their current illness, and realistic expectation about future deterioration and dying.

It is also essential to identify those individuals who would not want CPR to be attempted in the event of an arrest and who competently refuse this treatment option. Some people may wish to make an advance healthcare directive about treatment (such as CPR) that they would not wish to receive in some future circumstance. Such directives must be respected as long as the decisions are informed, current, made without undue influence from others, and clearly apply to the current clinical circumstance.

This policy is intended to prevent inappropriate, contraindicated and/or unwanted attempts at CPR which are of no benefit and may cause significant distress to patients and families. A death managed with inappropriate CPR treatment is undignified and highly traumatic. When a patient dies at home or in a care home, an inappropriate CPR attempt may also involve the Scottish Ambulance Service paramedics and even the police, which can add greatly to the distress of the families and be upsetting for all those involved. This policy supports the wider aim of ensuring that a person’s goals of care are known and respected at the end of life irrespective of whether they are being cared for in hospital, a hospice, a care home or in their own homes.

There is often confusion and uncertainty regarding CPR and the process of making advance decisions in which CPR will not be attempted. A consistent approach to decision-making, documentation and communication will help to avoid misunderstandings which can lead to harmfully distressing incidents for patients, families and staff. A single, integrated and consistent approach to this complex and important part of good end of life care is essential for all patients across Scotland.