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Background Decisions regarding Cardio-Pulmonary Resuscitation (CPR) and Do Not Attempt Resuscitation (DNAR) orders remain demanding, as does including patients in the process. Objectives To explore physicians’ justification for CPR/DNAR orders and decisions regarding patient inclusion, as well as their reports of how they initiated discussions with patients. Methods We administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion. Results Justifications were provided for 59% of DNAR orders and included severe comorbidity, patients and families’ resuscitation preferences, patients’ age, or poor prognosis or quality of life. Reasons to include patients in CPR/DNAR decisions were provided in 96% and 84% of cases, and were based on respect for autonomy, clinical assessment of the situation as not too severe, and the view that such inclusion was required. Reasons for not including patients were offered in 84% of cases for CPR and in 70% for DNAR. They included absent decision-making capacity, a clinical situation viewed as good (CPR) or offering little hope of recovery (DNAR), barriers to communication, or concern that discussions could be emotionally difficult or superfluous. Decisions made earlier in the patient9s management were infrequently viewed as requiring revision. Residents reported a variety of introductions to discussions with patients. Conclusions These results provide better understanding of reasons for CPR/DNAR decisions, reasons for patient inclusion or lack thereof, and ways in which such inclusion is initiated. They also point to potential side-effects of implementing CPR/DNAR recommendations without in-depth and practical training. This should be part of a regular audit and follow-up process for such recommendations.

Doctors are often reluctant to start conversations about resuscitation decisions. In four articles The BMJ squares up to decisions on “Do not attempt cardiopulmonary resuscitation” (DNACPR), to spark debate about an area of clinical practice often fraught with legal and ethical challenges. Zoe Fritz and colleagues describe how doctors are hesitant to raise DNACPR in case it distresses patients or leads to a complaint (doi:10.1136/bmj.j813; doi:10.1136/bmj.j876). But patients rarely start this conversation either, even though research shows that many older …

A legal case last year resulted in changes to the law on patient involvement in resuscitation decisions. Zac Etheridge and Emma Gatland set out the implications for doctors and hospitals

Background The East Midlands DNA-CPR form may be completed by a ‘suitably experienced nurse’. The BMA and RCN statement (2007) indicated that nurses may make such decisions, but ambiguity about training and governance remains. Senior community nurses, with previous advanced communication skills training, attended training using the e-ELCA Discussing ‘do not attempt CPR’ decisions. Subsequently nurses could take on the role of signing DNA-CPR forms if agreed by their employer. Aims To evaluate the impact of the training on practice and confidence. Methods: A questionnaire was sent 4 months after training and analysed descriptively. Results 13 of 36 questionnaires were returned. Those with patients on the LCP now completed the DNA-CPR form unless there were difficult dynamics. All completed it for any patient requesting DNA-CPR and 77% completed it with some patients for whom there was no chance of success from CPR. Where such patients or relatives were not in agreement the nurse sought involvement of a doctor. All nurses felt more confident to discuss the topic of CPR and much more confident in discussing a DNA-CPR decision for a dying patient (‘informing’ not ‘asking’), and in dealing with the reactions. Only one nurse reported more difficulties, arising with GPs who were less confident. None of the nurses had had their signature queried by a colleague or relative and many GPs were appreciative of this role. Only two nurses wanted formal assessment of their competence. Some considered assessment to add value if it enhanced the confidence of others in them. 55% wanted on-going CPD, considering this more likely than assessment to quality assure their practice. Conclusions The training increased confidence and has changed patient care. Senior nurses appear to assess the risk of their decision making role well and act appropriately. The role appears to have been well accepted.

A man plans to sue England’s health secretary, Andrew Lansley, and a hospital trust for allegedly imposing a “do not attempt to resuscitate” order on his wife without her express consent. David Tracey is taking legal action against Cambridge University Hospitals NHS Foundation Trust for allegedly failing to carry out cardiopulmonary resuscitation on his wife, Janet. He claims that the trust and the Department of Health for England acted unlawfully by not having a standard policy on resuscitation decisions. Mrs Tracey, who …

EDITOR—I was not surprised to see that national guidelines on resuscitation decisions are being ignored.1 I have worked in several hospitals on acute medical wards and often have seen fudged resuscitation decisions. I believe that the decision on resuscitation should, as with any treatment, be made by the patient first. If the patient is unable or too ill to make the decision it should be made in consultation with …