Scottish Government
Friday, 28 August, 2015

In 2010, the Scottish Government developed and implemented a national integrated “Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision-making and communication” policy.   A Children and Young Person’s Deteriorating Management (CYPADM) policy was also subsequently developed.A small core group has undertaken a review of the current policy documents over the latter part of 2014 and the early part of 2015 to ensure that they both reflect national good practice guidance “Decisions relating to Cardiopulmonary Resuscitation” from the British Medical Association, Royal College of Nursing and the Resuscitation Council (UK) that was published in October 2014 and are also consistent with the General Medical Council “Treatment and care towards the end of life: good practice in decision making” guidance.  The current revised draft documents were circulated. 

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
Comments on current revised draft documents from the Royal College of Physicians of Edinburgh

General comments

We have consulted with a number of our Fellows in order to offer comments on the Scottish Government’s policies and their associated guidance and forms on Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). We are not offering comments on the associated Children and Young Persons Acute Deterioration Management policies.

The policy documents

Overall, Fellows were supportive of this guidance and its content which reflects both the letter and spirit of the Cambridgeshire judgement[1]. It was however felt to be a long document, which might result it in being less likely to be read properly. The length may also result in some of the key messages (particularly that DNACPR discussions should not be held in isolation but as part of an overall discussion of the clinical picture; and that relatives should not be put in a position whereby they feel that they are being asked to make the decision) might get lost.

Large sections of the document discuss what is and is not CPR. This may be more helpful for lay audiences reading the policy, rather than healthcare professionals.

The discussion about the differences between DNACPR and allow natural death (AND) are somewhat confusing; the recommendation to use “AND” to indicate that only comfort care should be provided might be best removed. “Allow Natural Death” still causes confusion and healthcare professionals would best be encouraged to make specific, explicit instructions, e.g. “for comfort / palliative care only”, or “for antibiotic and fluids but not for NIV or other organ support; ward based ceiling of care”.

We agree that where no advance decision has been made regarding resuscitation, that there should then be an initial presumption in favour of providing CPR (page 12). The document could perhaps emphasise this more strongly as the overall impression of the document is of NOT providing CPR. Inappropriate CPR is clearly to be avoided, and is distressing for patients, relatives and staff, however, failure to attempt resuscitation when appropriate, or when doubt exists, can be equally harmful.  

The document does however provide more clarity regarding CPR not being offered if it is not an option. We also welcome the advice regarding training of health care professionals, but wonder whether this should be more explicit about providing training in how to manage situations where healthcare staff and patient views on the option (or not) of CPR differ.

The guidance does not really address what ‘psychological distress’ constitutes. Clearly, whilst this is more than just becoming upset, it leaves room for subjective physician judgement about whether to discuss DNACPR decisions or not.

The introduction refers to cardiopulmonary arrest representing a terminal event in a patient's illness or in the context of illness. It would be beneficial to also include specific consideration of frailty. Frailty is not in itself an illness and may therefore not be recognised by all as relevant to end of life discussions, but can of course lead to death without a specific intercurrent illness, or with a short and unexpected illness with no time to discuss CPR with the patient.

There is perhaps some ambiguity on page 7- paragraph 2. All the measures listed as not being included in CPR are fair, with the exception of investigation and treatment of a reversible condition. Whilst not part of the "mechanics" of CPR, a search for reversible causes is integral to resuscitation. The guidance later goes on to mention situations such as surgery/anaesthesia where a potentially reversible cause of cardiopulmonary arrest should be considered even when a DNA CPR exists.

The framework in Annex A is helpful and would be useful to publish as part of the DNACPR form booklet.

The patient information booklet (Appendix iii) is generally very helpful. However the wording is not entirely candid and therefore may confuse patients if at odds with what their clinician tells them. In particular, “unfortunately, CPR often does not work” is arguably misleading, presumably to avoid frightening patients. There is plenty of data out there to demonstrate that CPR usually doesn’t work, or at least doesn’t result in sustained success to the extent of ever making it out of hospital – this kind of information is important to include as it allows truly informed decision making by patients.

The choice to name some supporting documents as “Annex” and others as “Appendix” is confusing. Annexes are documents which are included but could also stand-alone. Arguably, therefore, all the appendices are actually annexes except for the one about patients with CIEDs (appendix iv).

The DNACPR Form (Appendix i)

This form was felt to be much more comprehensive than the current available documentation, which is to be applauded. This potentially makes it more time consuming to complete.

The ability to clarify that the conversation around ‘decision not to resuscitate has not yet happened’ is helpful.  The current inability to clarify this on the form probably accounts for why some patients do not have an appropriate form in situ (which may result in an increase in cardiac arrest calls being made for patients inappropriate for resuscitation). This will help address this.

There is a fine line between stating that CPR would not be successful versus stating that it could be successful, but that the likely outcome would not benefit the patient where the patient has capacity but doesn’t want to discuss the issue; it depends on what “successful” is interpreted as but appears to be a grey area.

In terms of naming multidisciplinary team members involved in the decision, the form doesn’t clarify who should be included; for example, the consultant may discuss with others to ensure everyone agrees with / is comfortable with the decision, but does inclusion of additional names imply additional responsibility for this?

The statement at the bottom of the first page reads "This original DNACPR Form should follow the patient." It is sometimes the case that patients or families are accepting of a DNACPR form in hospital but are not quite ready to have a DNACPR form in the home, so perhaps this could be further qualified – for example "with the agreement of the patient and / or family".

The option to not review the decision as it remains clinically appropriate for the rest of their life is helpful and it probably applies in the majority of cases. Currently staff have had to artificially insert a date (often “on discharge” which has meant that subsequent teams have had to address this decision and documentation repeatedly on subsequent admissions – inappropriately distressing to patients/families and time consuming for staff). The recommendation that it is good practice to review the decision whenever clinical responsibility is transferred is also welcome.

The section to clarify who this has been communicated with is helpful although there are some doubts that this will be reliably completed.

The final section on communication with ambulance crew could be ambiguous as to whom to contact and where to take the patient, and how this decision is reached. More guidance may be needed on how this decision is arrived at.

Finally, guidance on the form could contain more information on the reversal of the form – for example drawing lines or writing ‘reversed’ on any copies; although it is appreciated that the original should stay with the patient.


[1] Tracey v Cambridge Uni Hospital NHS Foundation Trust & Ors.