If a patient requests that you include a do not attempt resuscitation (DNAR) order in their medical records while they are at home, you should fully explore with the patient, and those close to them if they wish, the reasons for the request, to identify and understand any concerns they may have.
A concern the patient may have for example, could be that his advance wishes and instruction may not be seen, and therefore not followed, by anyone who may be involved in his care in the future. In this case, it would be important to explain fully the systems in place locally to prevent this.
The GMC1 and the Joint statement (guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing on decisions relating to cardiopulmonary resuscitation) both state that any decision about whether to attempt CPR or not, must be recorded clearly in the patient’s main health record which should be easily-accessible to all healthcare professionals who may need to know.
This could include secondary care staff, hospices, care homes, out of hour’s medical services and ambulance clinicians. There is also a professional obligation to handover and communicate any CPR decision when a patient is transferred from one setting to any other.
The Joint Statement recommends that DNAR decisions should be recorded on standard forms such as that produced by the Resuscitation Council UK. This ensures that they are compliant with legislation, consistent and easily recognised across geographical and organisational boundaries.
DNAR forms can be in paper or electronic form, but should be of a similar format and content regardless of the form employed.
The documentation should clearly show the applicability and validity of a DNAR decision, so that any treating clinician can be confident of its purpose.
This can be included on the DNAR form, in the health record, or in some cases both, and should document the patient’s capacity, the clinical basis for the decision, a summary of the communication with the patient, friends or family or legal proxies and the decision’s review status.
Generally, it is recommended that DNAR forms should not be copied. Where copying is permitted, there should be a clear policy and mechanisms in place to ensure that if a decision is cancelled, then this is disseminated to all existing copies.
There are many different systems for ensuring that DNAR decisions are disseminated to everyone who may be involved in the patient’s care. Agreed standard forms recognised by all healthcare providers, police and ambulance services can assist with this process.
When paper-based these can be transferred with the patient or if held electronically, should usually be stored in a location which allows appropriate access to all relevant parties. However, centrally-held electronic DNAR form systems should include a clear policy on the action to be taken in the event that personal access to the database is not possible.
There are likely to be local policies and procedures in most areas which will determine local requirements for storage, access, review and communication in relation to DNAR decisions and it is important that these are consulted and complied with.
The patient should also be encouraged to inform everyone who may need to know of their DNAR decision and the location of their form and this may include family members, friends and carers.
- Dr John McGuire is a medicolegal adviser at Medical Protection
1. GMC. Treatment and care towards the end of life, 2010 paragraph 75