Confusion over DNAR orders

Foster and Hope ¹ describe ‘… considerable confusion over the status of “do not attempt resuscitation” (DNAR) orders’. Their analysis of the legal status of these orders is clear but does not explain why there is confusion; they may also underestimate some practical difficulties.

The Mental Capacity Act (MCA) provides measured and nuanced rules, but those who draft statutes do not always have to consider practical implementation. They might assume that all clinical staff can be meticulously trained in every implication and can comply with complex rules in the, often chaotic, circumstances of arrests.

Elective assessment of capacity must be measured and nuanced, but the person witnessing a cardiac arrest has to act more pragmatically. The authors note that this is often a nurse, but he or she might not conduct assessments of capacity and might not receive such detailed training as medical staff in the implications of the MCA and DNAR orders. Patients often move between wards, but accurate information and knowledge often do not follow. The authors ‘hope’ that DNAR reviews have occurred and ‘should’ be in handovers may be overoptimistic.

They state that the first decision at an arrest must be whether or not to call the resuscitation team; actually, it is whether to start basic life support. It is this decision that could result in the nurse risking a charge of battery, as the authors warn, or of accusation of not attempting resuscitation later thought to have been indicated. They further state that the first decision must legally be made at the time of the arrest, either on the basis of an order's validity and applicability or of the patient's best interests, as assessed at that time. The authors might try to estimate a minimum time needed for such an assessment, particularly with inadequate notes. I suspect that it exceeds the short window of opportunity to secure even the small chance of successful resuscitation.

None of this negates the authors’ helpful analysis, or the need for correct implementation, but some clinical circumstances can confound the best legal and ethical intentions. I wonder how many nurses will read the essay.