Resuscitation policy should focus on the patient, not the decision
BRITISH MEDICAL JOURNAL | Online – 28 February 2017 – Do not attempt cardiopulmonary resuscitation (DNACPR) decisions are made commonly in healthcare, but can be a source of ethical concern and legal challenge. They differ from other healthcare decisions because they are made in anticipation of a future event and concern withholding, rather than giving, a treatment. DNACPR decisions were introduced to protect patients from invasive treatments that had little or no chance of success. However, inconsistencies in decision making, communication, and documentation have led to misunderstandings about what DNACPR means and to delivery of poorer care to some patients. The authors discuss the problems with current practice and outline newer approaches that place the patient, and their family, at the centre of the discussions. They focus on overall treatment plans and supporting clinicians and patients to make shared decisions about emergency treatments. Given the weight of evidence against DNACPR decisions being made in isolation, how much (and what kind of) evidence is needed before a new approach is adopted? Some of the principles underpinning the new approaches to resuscitation decisions are already widely accepted – clinicians need to understand what is important to each individual patient and to advise their patients which outcomes are clinically possible or likely. Others are drawn from the research literature –conversations should be undertaken proactively before a crisis occurs; the option of attempting CPR should be discussed with more people, not just those needing DNACPR decisions or approaching the end of life; resuscitation decisions should be contextualised within overall goals of care. The aim of ensuring that recommendations are documented in such a way that patients receive the right treatments at the right time is one which is universally accepted.