Cardiopulmonary resuscitation (CPR)

If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful in restarting breathing and circulation, discussing, making and recording a decision in advance not to attempt CPR can help to ensure that the patient dies in a dignified and peaceful manner. It may also help the patient achieve their wish of spending their last hours or days at their preferred place of death. These management plans are called Do Not Attempt CPR (DNACPR decisions and are best made in the wider context of advance care planning (see paragraphs 50-55 and glossary). A recorded DNACPR decision is not, in itself, legally binding and should be regarded as a clinical assessment and decision, made and recorded in advance by the person with lead responsibility for the patient’s treatment and care, to guide immediate clinical decision-making in the event of a patient’s cardiorespiratory arrest. 

In cases in which CPR might be successful in restarting breathing and circulation, it might still not be seen as clinically appropriate because of the potential for poor clinical outcomes. When considering whether to attempt CPR, you should consider the benefits, burdens and risks of treatment that the patient may need if CPR results in the return of a spontaneous circulation. In cases where you assess that such treatment is unlikely to be clinically appropriate, you may conclude that CPR should not be attempted. Some patients with capacity to make their own decisions may wish to refuse CPR; or in the case of patients who lack capacity it may be judged that attempting CPR would not be of overall benefit to them. However, at the time they suffer a cardiac or respiratory arrest and an immediate decision has to be made, it can be difficult to establish the patient’s wishes and preferences or to get relevant information about their underlying condition to enable a fully informed assessment. So, if a patient has an existing condition that makes cardiac or respiratory arrest likely, establishing a management plan in advance will help to ensure that the patient’s wishes and preferences about treatment can be taken into account and that, if appropriate, a DNACPR decision is made and recorded.

If a patient is admitted to hospital acutely unwell or becomes clinically unstable in their home or other place of care, and they are at foreseeable risk of cardiac or respiratory arrest, a judgement about the likely success of CPR in restarting breathing and circulation and its benefits, burdens and risks should be made as early as possible. You should also check whether any form of advance care planning is already in place and, if the patient lacks capacity, whether they have a legally binding advance refusal.

As with other treatments, decisions made in advance about whether CPR should be attempted must be based on the circumstances of the individual patient and take into account their wishes and preferences.  It should also involve discussions with members of the healthcare team as well as (with the patient’s agreement) those close to the patient. You must approach discussions sensitively and bear in mind that some patients or those close to them, may have concerns that decisions not to attempt CPR might be influenced by poorly informed or unfounded assumptions about the impact of disability or advanced age on the patient’s quality of life.

If a patient lacks capacity to make a decision about future CPR, you must consult those close to the patient as part of the decision making process. You must approach discussions sensitively and bear in mind that some people may have concerns that some decisions not to attempt CPR might be influenced by poorly informed or unfounded assumptions about the impact of disability or advanced age on the patient’s quality of life. In addition, the views of members of the healthcare team involved in their care may be valuable in assessing the likelihood that CPR would be successful in restoring the patient’s breathing and circulation or whether successful CPR would likely be of overall benefit to them. You must make reasonable efforts to discuss a patient’s CPR status with these healthcare professionals. 

If a patient is at foreseeable risk of cardiac or respiratory arrest and the person with lead responsibility for the their treatment and carejudges that CPR should not be attempted, because it will not be successful in restarting the patient’s heart and breathing and restoring circulation, this must be sensitively discussed with the patient unless this would cause them serious harm. In this context, ‘serious harm’ means more than that the patient might become upset. The purpose of the dialogue is to reach a shared understanding with the patient about their situation, the judgement and the reasons for reaching it. You must listen to the patient and you should encourage them to ask questions. As part of these discussions, you should explore with the patient the type of information they want or need, their wishes or fears and explain that they have a right to seek a second opinion. While some patients may want to have these discussions, others may not. You should not force a discussion or information onto the patient if they do not want it. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.  

If 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 necessary information they may need to know in order to support the patient’s treatment and care. You should emphasise to the patient that they may discuss the topic at any time if they decide that they want to.

If a patient lacks capacity, you must consult with  any legal proxy and others close to the patient about the DNACPR decision and the reasons for it unless it is not practicable or appropriate to do so. These discussions should take place at the earliest practicable opportunity and should include a sensitive and careful explanation that the intention is to spare the patient treatment that will be of no benefit, not to withhold any other care or treatment the patient will need.

If there is disagreement about whether CPR should be provided, you should try to resolve it by following the guidance in paragraphs 47 - 49.

Any discussions with a patient, or with those close to them, about whether to attempt CPR, and any decisions made, should be documented in the patient’s record and any advance care plan.³⁸  If a DNACPR decision is made and there has been no discussion with the patient because they indicated a wish to avoid it, or because it was considered that discussion with the patient would cause them serious harm, you should document this fully in the patient’s records. 

In your consultations and discussions about CPR, you must make it clear to the healthcare team, the patient and those close to the patient that a DNACPR decision applies only to CPR. It does not imply that other treatments will be withdrawn or withheld. Other treatment and care will be provided if it is clinically appropriate and agreed to by a patient with capacity, or if it is of overall benefit to a patient who lacks capacity.

A DNACPR decision should not override your clinical judgement about CPR if the patient experiences cardiac or respiratory arrest from a potentially reversible cause, that was neither discussed nor envisaged when the DNACPR decision was recorded. If a patient with a DNACPR decision in place has a planned procedure which could precipitate a cardiorespiratory arrest, such as an operation under general anaesthesia, there should be careful discussion with the patient (or with those close to a patient who lacks capacity) beforehand to reach agreement about possible temporary suspension of the DNACPR decision. 

Emergencies can arise when there is no time to access all relevant information about the patient’s condition and the likely outcome of CPR; when no previous DNACPR decision is in place; and when it is not possible to find out the patient’s views. In these circumstances, CPR should be attempted, unless, in your clinical judgement, it will not be successful in restarting the patient’s breathing and circulation.