Why you need to know about DNAR

Reviewed by Dr Patrick Ruane

As your parents age and increasingly confront health issues, it helps to familiarise yourself with certain medical terms to best support their care and wellbeing.

Among these terms, DNAR (Do Not Attempt Resuscitation) and DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) are particularly critical to understand when they are in very poor health or later-stage terminal illness.

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What does DNAR stand for?

DNAR stands for “Do Not Attempt Resuscitation.” A DNAR order is a directive issued by a doctor to medical staff to communicate that in the event of a patient’s cardiac arrest (their heart stops beating) or respiratory arrest (their breathing stops), cardiopulmonary resuscitation (CPR) should not be used to restart their heart or breathing.

DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) and DNR (Do Not Resuscitate) are terms that are also commonly used interchangeably and mean the same thing.

Recognising and understanding these terms is crucial for navigating discussions surrounding treatment and end-of-life care for your parents and elder loved ones.

Why is it not always good to perform CPR on an elder person?

People generally overestimate the success of CPR, and underestimate the negative impact it can have on health. While you’ve likely seen CPR being portrayed as a life-saving measure in television shows and documentaries, it’s important to understand that CPR isn’t always the best treatment option. In reality, CPR can be a traumatic intervention, potentially causing rib fractures, internal organ damage, and other complications.

When someone is very old and frail or terminally ill and near end of life, medical professionals may determine that CPR would be unlikely to save their life, but may instead prolong their suffering and disrupt the possibility of a peaceful and dignified death. For example, if someone has a terminal illness with widespread organ failure, then CPR could make their condition worse, potentially leading to unnecessary pain and distress without offering much benefit.

What is the controversy around DNAR?

DNAR decisions must be made on an individual basis and not for groups of people. However, during the COVID-19 pandemic, reports of blanket age policies for DNAR orders raised ethical concerns and sparked public outcry in the UK.

Healthcare professionals and advocacy groups have since emphasised the importance of approaching DNAR decisions with sensitivity and openness, leading to recommendations for doctors and healthcare teams to engage in thorough discussions about DNAR with patients and their families.

How do DNAR orders work?

Doctors typically issue a DNAR or DNACPR form in situations where they think attempting CPR wouldn’t work, would prolong suffering or would cause more harm than good. It’s important to know that a DNAR or DNACPR order only specifies that a person should not receive CPR, and does not mean they won’t receive appropriate, supportive treatment for their other health issues and personal care needs.

Once issued, DNAR forms are kept on the person’s medical record.

If a DNAR form has been issued for your parent or an elder relative in your care, they should be made aware that this decision has been made. The only reason a doctor may not tell you or your parent that a DNAR form has been put in place is if they think doing so would cause them physical or psychological harm.

Bear in mind that a doctor does not need your or your parent’s consent to issue a DNAR order for them. In other words, it’s a medical decision they can make whether or not you or they agree.

A DNAR order can also be put in place if your parent or elder relative requests it (as long as they are deemed to have ‘mental capacity’ when they request it – i.e. they are still capable of making decisions for themselves). They can do this in advance and make it legally binding by completing something called an Advance Decision to Refuse Treatment (ADRT) – also known as a ‘living will’.

Can a DNAR order be overridden?

DNAR decisions made by doctors and medical teams are based on the individual person’s health condition and realistic chances of survival.

If you have any concerns about a DNAR issued for your parent or elder relative, you should raise it with their medical team, and if necessary, ask for a second opinion. If you are still unhappy, you can escalate your concerns via the hospital’s appropriate complaint’s procedures. You can also contact your local Healthwatch to find out about how to get help making a complaint.

While there are rare circumstances where DNAR orders may be challenged or overridden, such decisions are subject to careful consideration and legal scrutiny.

DNAR requests are not legally binding unless an Advance Decision to Refuse Treatment (ADRT) has been completed by your parent or elder relative themselves.

In summary

DNAR is an important term to understand when you are supporting or caring for elderly parents or relatives. It’s also important to understand that CPR is not always an appropriate treatment for someone, particularly if they are very old, frail and near end of life.

Proactively discussing DNAR and end-of-life preferences in advance with your elder parents and relatives can help to alleviate any uncertainty about what to do if a medical emergency arises and they are unable to discuss it or make a decision at the time.  By engaging in these conversations early on, you and your parent or elder relative can establish a shared understanding of their end-of-life preferences and develop a plan for emergency situations.

If a doctor issues a DNAR or DNCPR order for your parent or an elder relative under your care, they will typically discuss the decision and reasoning behind it with your relative and you, but this can vary depending on the situation and your parent or relative’s wishes.

Common questions

Is a DNAR legally binding?

A DNAR issued by a doctor for medical reasons is not a legally binding document, it is a guide to other health professionals indicating that they should not perform CPR on the patient in an emergency. However, if your parent or elder relative completes an Advance Decision to Refuse Treatment (ADRT), this document is legally binding and must be followed by healthcare professionals.

When should a DNAR decision be considered?

A DNAR decision is usually considered when someone has a terminal illness, advanced frailty, or a medical condition where attempts at resuscitation may not be effective or could cause more harm than good.

Can family refuse DNAR?

In most cases, family members cannot refuse a DNAR order issued by a healthcare professional. However, they can discuss their concerns and preferences with the medical team involved in the decision-making process and request a second opinion.

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