Canterbury DHB

Context

Making Resuscitation Decisions - Information for Doctors

Cardiopulmonary Resuscitation (CPR) can be lifesaving, particularly in the hospital context where effective CPR can be commenced very quickly. Cardiac arrest can be due to an acute and potentially reversible event such as an MI or metabolic causes such as hyperkalaemia. In these situations, CPR can be effective at restoring cardiorespiratory function and allowing recovery. More commonly, however, cardiac arrest is the final event in the dying process and for many patients with advanced illness, CPR has virtually no prospect of success and may be either unsuccessful or leave the patient worse off.

CPR is the default option within all health care facilities in New Zealand unless an advanced decision is made that CPR should not be attempted. DNACPR stands for "Do Not Attempt Cardiopulmonary Resuscitation" and is the current agreed terminology in the CDHB. DNACPR is the medical order which indicates that CPR should be withheld allowing the death of that patient from natural causes or inevitable progression of their illness. CPR may be withheld for 3 reasons:

  1. The patient does not wish it to be performed and requests that it be withheld. This request may be made verbally and result in the completion of a DNACPR form. The patient request also may arise via an advance directive. Advance directives are explained below.
  2. More commonly, a DNACPR decision arises out of a conversation with a patient, with or without family/whānau present. This conversation should ideally be part of a broader conversation about their condition and prognosis and may be prompted because of a concern by the medical team that CPR would be inappropriate, unwanted, or futile.
  3. DNACPR decisions may also be made by the medical team on behalf of incompetent patients who are unable to share in the decision, or occasionally in isolation from a patient who is imminently dying. These decisions are sometimes referred to as "medically initiated" DNAR decisions. In both these circumstances the decision not to attempt CPR must be on the grounds of it being in the patient’s "best interests" to withhold CPR. Where the patient is unable to participate in the decision, the NZ Code of Rights requires that the medical team makes a reasonable attempt to discover and consider the patient’s prior wishes and also the views of others such as family/whānau. The decision, however, is ultimately made by the medical team.

The DNACPR Form

The DNACPR form allows one of two options to be chosen:

  1. The first option is "time limited". This is consistent with the previous forms where the decision is limited to 2 weeks duration. After this time the decision needs to be remade or it lapses and becomes void.
  2. Alternatively, an "enduring" DNACPR decision can be made in either of these circumstances:

    This decision might be reached after discussion with the medical team, especially in cases where the patient has advanced progressive or terminal illness. An enduring DNACPR order in these circumstances means that the issue does not need to be repeatedly raised and discussed with the patient and the decision can be carried over from one admission to the next. Also, the decision should be communicated through to community providers such as residential care facilities and General Practitioners, either verbally or by inclusion in the discharge summary.

Initiating the discussion

Important requirements when authorising a DNACPR order

Issues of concern to doctors

Niki T34 Syringe Driver

There will be copies of the virtual syringe driver available in the Professional Development Unit to play with.

CDHB Procedure for Setting Up T34 Syringe Driver

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155 kb

T34 Syringe Driver - Instruction Manual (Nurse Maude)

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267 kb

Inpatient Syringe Driver Observation Chart

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124 kb

Syringe Driver Compatibility Chart

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103 kb

Authority for Administration of Prescribed Medication via Continuous Subcutaneous Infusion (Document No:7418)

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113 kb

Authority for Administration of Prescribed Medication (Document No:4203)

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106 kb

About this Canterbury DHB document (39249):

Document Owner:

Kate Grundy (see Who's Who)

Issue Date:

February 2016

Next Review:

February 2018

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 39249