Decision-making in intensive care: Influence of DNACPR status

Editor,

The findings of the engaging review article by James et al. ¹ raise an interesting ethical consideration.

The authors found that the presence of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order was associated with a significantly higher rate of non-acceptance to critical care by reviewing intensivists. Although association and causation are separate entities and the extent to which this individual factor contributed to the decision is uncertain, it is conceivable that DNACPR status may in some cases trigger heuristic decision-making on the part of the intensivist regarding the decision of whether or not to admit to critical care.

When speaking to patients and their relatives about resuscitation status, we frequently make assurances that DNACPR applies to CPR alone, and that no other aspect of care will be affected; this intent is in line with established national guidance. ² Despite this, there exists evidence that a DNACPR order does negatively influence the likelihood of a variety of both medical and nursing interventions, including referral to critical care from parent teams.^3–5

Is it therefore possible that we are inadvertently denying access to critical care to patients who may benefit from it, and how can we address this problem? Should intensivists be initially blinded to DNACPR status when reviewing critical care referrals in order to minimise this heuristic bias?