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 Government introduced the Advance Decision on Life-sustaining Treatment Ordinance (“the Ordinance”), with a view to establishing corresponding legislative frameworks for advance medical directives (“AMDs”) and do-not-attempt cardiopulmonary resuscitation (“DNACPR”) orders. 

To facilitate adherence to instructions in an AMD in situations demanding immediate decisions without the presence of medical professionals (e.g. outside the hospital setting), registered medical practitioners (“RMPs”) may make AMD-based DNACPR orders for AMD makers who have specified in their underlying AMDs a refusal of cardiopulmonary resuscitation ("CPR"). AMD-based DNACPR orders instruct not to perform CPR on the subject person under applicable circumstances when that person is in a cardiopulmonary arrest.

• DNACPR orders must be made in writing using a prescribed form for easy identification and verification. 
• The types of DNACPR orders that may be made are—
  1. a DNACPR order that is AMD-based;
  2. a DNACPR order that is not AMD-based and is made for an adult who is mentally incapable of deciding on a life-sustaining treatment; and
  3. a DNACPR order that is not AMD-based and is made for a minor.
• The order must be signed by 2 registered medical practitioners and one of them must be a specialist
• The effective period will not exceed 12 months. If renewal is required, only one doctor's signature is required, and each renewal cannot exceed one year.
• The date of signing must be shown.
• Since the patients in cases (a) and (b) are not capable to make AMDs leagally, if the patient's responsible person (such as a family member, a cohabitee, a legal guardian, etc.) agrees, after consulting with the doctor who signed DNACPR order, that performing CPR on the patient in a state of cardiopulmonary arrest would not be in the best interests of the patient, this responsible person must also countersign the DNACPR order.

The Ordinance follows the “cautious making, easy revoking” principle.

A DNACPR is revoked in the following situation:

• A DNACPR order is revoked if the content of each page of the order is crossed out; and one specialist and one registered medical practitioner signed on each page.
• A AMD-based DNACPR is revoked if the AMD is revoked.
• A DNACPR order made for a person who is under the age of 18 years is revoked when the person reaches that age.
• A DNACPR order made for an adult who is mentally incapable of deciding on a life-sustaining treatment is revoked when the adult ceases to be so mentally incapable.
• A new DNACPR order is issued and the original order is revoked.

1. If an AMD is already made, is it necessary to make a DNACPR order? What is the difference between the two instruments?

While both AMD and DNACPR order entail instructions on the refusal of CPR, the two legal documents are slightly different in nature.

AMDs are made and signed are by the patient, and doctors can issue and sign DNACPR orders based on the AMDs signed by the patient.

An Advance Medical Directive

• • An AMD is made by an adult who is mentally capable of deciding on an LST, indicating the LST (e.g. CPR) he/she wishes to refuse when he/ she becomes mentally incapable in the future.
  • Specifically, at the time of making an AMD, the maker’s condition may not have reached the specified preconditions (e.g., being terminally ill).
  • The treatment provider’s obligations and liabilities relating to subjecting, or not subjecting, the maker of an AMD to an LST are subject to a valid and applicable instruction in the AMD.
  • Irrespective of the patient's location, whether in or outside the hospital setting, treatment providers would not provide LST to the patient when they have notice of the patient’s AMD and the instructions therein are valid and applicable.

A DNACPR order

• • is made on the grounds of RMP’s clinical judgements based on the patient’s current clinical condition.
  • is a clinical decision made by two RMPs during the EoL stage of the patients.

The key advantage of a patient having both an AMD and a DNACPR order is to ensure that outside a hospital setting, even in the absence of treatment providers, rescuers can comply with the order and will not perform CPR on the patient if they have notice of the DNACPR order.

Considering the patient’s individual circumstances, healthcare professionals will engage in a thorough discussion with the patient and family members to determine the necessity of making the two instruments simultaneously.

2. If the patient has a DNACPR order made by RMPs, and the rescuers cannot locate the validating copy of the order upon arrival at the patient’s residence, will they conduct a search for the order?

The patient has the responsibility of presenting his/her DNACPR order to treatment providers and rescuers.

Since DNACPR orders may be followed outside the hospital setting during emergencies, the Ordinance will stipulate that treatment providers and rescuers are not required to search the patient’s personal belongings for a validating copy of the DNACPR order. If rescuers do not have notice of any DNACPR order or validating copies, they will administer prompt and proper treatment on the premise of saving lives.

To aid patients in carrying DNACPR orders, the Hospital Authority will prepare eye-catching designed pouches. The pouches will be clearly labelled as containing a DNACPR order, permitting rescuers (e.g. fire and ambulance personnel of the Fire Services Department) and other relevant individuals to search for the order therein. DNACPR orders should be positioned in a highly visible location for easy identification and quick access by family members or rescuers.

Model Forms of Advance Medical Directive (AMD)

• Advance Medical Directive (AMD)
• AMD (For Refusal of Cardiopulmonary Resuscitation Only)

Statutory Forms and Continuation Sheets of Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR) Order

• DNACPR order (AMD-based)
• DNACPR order (not AMD-based) (For Mentally Incapable Adult)
• DNACPR order (not AMD-based) (For Minor)
• Continuation Sheet for DNACPR order (For Adult)
• Continuation Sheet for DNACPR order (For Minor)

Health Bureau: Advance Decision on Life-sustaining Treatment Ordinance

Hong Kong e-legistration: Advance Decision on Life-sustaining Treatment Ordinance