What is ‘DNACPR’?
DNACPR is an acronym; it stands for “Do Not Attempt Cardiopulmonary Resuscitation.” Cardiopulmonary resuscitation (CPR) is a first aid procedure that can be administered when a person’s heart stops beating (‘cardiac arrest’) and/or they stop breathing (‘respiratory arrest’). Artificial ventilation, such as ‘mouth to mouth,’ delivers oxygenated air to the lungs, and a tube may be inserted into the throat in order to keep the airway open. Chest compressions are used to keep oxygenated blood circulating to the vital organs, while a defibrillator, which delivers electric shocks, may be used to correct the heart’s electrical impulses.
CPR can and does save lives. When a shock from a community defibrillator is administered in the case of out-of-hospital cardiac arrest, the survival rate is 32%, and the introduction of these defibrillators has seen overall survival rates following out-of-hospital CPR double in the last decade. More information about these defibrillators can be found on the British Heart Foundation’s website.
However, the success rate of CPR is extremely variable, and dependent upon the nature and circumstances of the cardiac arrest. The heartbeat is produced by electrical impulses in the heart. In some cases, although a person’s heart stops beating, some electrical activity still occurs, and an electric shock from a defibrillator can sometimes correct the electrical activity and restore the normal heartbeat. When a community defibrillator is used in these cases, the survival rate is 57%. CPR can therefore be very effective, for example when the cause of the cardiac arrest is an abnormality in the electrical activity of the heart.
In other cases, however, CPR is unlikely to be successful. Sometimes, the heart’s electrical activity ceases completely (‘asystolic cardiac arrest’) and the heartbeat cannot be restored using a defibrillator. Overall survival rates in cases of asystolic cardiac arrest are around 2%. Cardiac arrest may also occur at the end stage of a dying process caused by a terminal illness. In these cases, because the underlying cause of the cardiac arrest cannot be addressed, CPR is much less likely to be successful. Even if the heartbeat can be restored temporarily, CPR may serve only to prolong the dying process. CPR is also much less likely to be successful among those who are particularly frail. The in-hospital CPR success rate among the most frail patients is 1.8%, compared to 56% among the least frail. Research has shown that, overall, public perceptions of success rates far outstrip the reality.
As well as having highly variable rates of success, CPR can leave a person with significant physical and cognitive damage. Chest compressions can break ribs, and more than 1/4 of those who survive following CPR meet the criteria for post traumatic stress disorder. A lack of oxygen to the vital organs resulting from cardiac arrest can leave the person with residual brain damage. Some people will never regain consciousness. For these reasons, CPR is not always the right response, and the benefits of performing CPR must be carefully weighed against the risks.
Some people choose to sign an ‘Advance Decision to Refuse Treatment’ (ADRT). An ADRT is a legally binding document that tells clinicians that you do not want to receive CPR should you experience a cardiac arrest. A person must have the capacity to make the decision in order for the ADRT to be valid, and it must be in writing and signed by both the person and a witness.
Even when someone has not signed an ADRT, doctors may recommend that, if the person suffers a cardiac arrest, CPR should not be performed. They might do this because there is no reasonable prospect that CPR will be effective, or because the risks of performing CPR outweigh the benefits. They will record the DNACPR recommendation on a DNACPR form.
DNACPR recommendations are not legally binding. This means that, at the point of cardiac arrest, the clinician may decide to perform CPR even if a DNACPR recommendation has been recorded. One ground for doing so might be that the DNACPR recommendation has been made on the basis that the person is suffering from a terminal illness, but the present cardiac arrest has a separate and reversible cause. In all cases, while they should take the DNACPR recommendation into consideration, the clinician attending to the person in cardiac arrest takes final responsibility for decision to withhold or administer CPR.
The terms ‘Do Not Resuscitate’ (DNR) and ‘Do Not Attempt Resuscitation’ (DNAR) are sometimes used instead of DNACPR. This is potentially misleading, since ‘resuscitation’ can also refer to anything that brings a person back to consciousness, such as giving them fluids. DNACPR recommendations apply very narrowly to CPR, and the presence of a DNACPR recommendation should not influence any other forms of care or treatment. The term ‘DNACPR decision’ is also often used. However, it is important to note that DNACPR recommendations are not legally binding, and the clinician attending at the time of cardiac arrest is ultimately responsible for deciding whether to perform CPR. For these reasons, we refer throughout to ‘DNACPR recommendations’.