DNACPR

Cardiopulmonary Resuscitation (CPR) is an emergency procedure for a person suffering cardiac arrest. The steps involved are (1) performing chest compression to restore blood flow temporarily; (2) ensuring an unobstructed airway; (3) using artificial ventilation in place of autonomous breathing. 

Healthcare workers will also use drugs and automated external defibrillators as appropriate to restore the patient’s normal heart rhythm.

CPR is an invasive emergency intervention, the outcome of which depends on various factors. 

• As the underlying factor of a terminally ill patient such as cancer and organ failure causing cardiac arrest has not changed, the successful rate of CPR resulting in effective rescue is very low.
• Also, CPR may cause complications, e.g. rib fracture. Performing futile CPR on a dying patient can only prolong the dying process which causes unnecessary pain and suffering.
• For other kinds of LST, it may simply be impossible to sustain life in certain end-stage situations. In other situations, though LST can temporarily sustain life, the disease condition is irreversible. These interventions can only prolong the dying process which may be of little meaning to the patient, or even aggravate their suffering and thus not in the best interests of the patient.
• Overall speaking, adopting the palliative care approach instead of curative treatment is more appropriate for the advanced cancer patient. A peaceful journey to a dying patient is more appropriate.

Firstly, euthanasia is defined as “direct intentional killing of a person as part of the medical care being offered”, which is in essence killing a patient to end their suffering. The act can be considered as criminal and is ethically controversial. 

Same as most places in the world, Hong Kong does not legally permit euthanasia and it violates the professional ethics of healthcare workers. 

However, the patient has the right to refuse unwanted treatment, including LST such as Cardiopulmonary Resuscitation (CPR). A healthcare professional who provides treatment against the patient’s will may be liable to legal action for battery or assault. 

Withholding such treatment in this case is an act of respecting the patient’s wish and ensuring them a peaceful death. This is not tantamount to performing euthanasia. 

Withholding or withdrawing futile treatment for a patient is not performing euthanasia as the treatment is not in the best interests of the patient. Administering futile LST on a dying patient would only inflict more suffering. What the patient needs in the final days is not futile treatment, but end-of-life care and a peaceful death.

Do Not Resuscitate (DNR), Do Not Attempt Resuscitation (DNAR), and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) all refer to the same decision when patient is terminally ill, CPR is not to be initiated on the patient, based on prior deliberations between the patient/family and the healthcare team. 

The Hospital Authority (HA) Guidelines on Do-Not-Attempt Cardiopulmonary Resuscitation promulgated since 2014 have chosen to adopt the full descriptive name, DNACPR, so as to emphasize that the plan is strictly referring to the treatment option of CPR only, and does not automatically imply whether the patient will or will not be receiving other life-sustaining treatments. DNACPR is also the term used in relevant documents of NHS and GMC of UK.

The DNACPR form assists the receiving health care team by telling the receiving healthcare team that the AD was validly made and the condition of the patient as presented to the original health care team falls within the AD. 

The receiving healthcare team may decide not to perform CPR if they are satisfied that the AD has not been revoked (i.e. DNACPR remains valid and unchanged), the condition of the patient as presented to them falls within the AD and no untoward event is suspected. The patient is advised to attach the AD to the DNACPR form (non-hospitalized patients).

Hospital Authority: Advance Care Planning (ACP)? Advance Directives (AD)? Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR)? Patients and families should know more!

HA Guidelines on Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR) (2020)