Variation in local trust Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies: a review of 48 English healthcare trusts

Objectives: To explore Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies from English acute, community and ambulance service Trusts for evidence of consistency and variation in implementation of national guidelines between healthcare organisations. Setting: Acute, community or ambulance National Health Service (NHS) Trusts in England. Participants: 48 NHS Trusts. Interventions: Freedom of information requests for adult DNACPR policies were sent to a random sample of Trusts. Outcomes: DNACPR policies were assessed on aspects identified from national guidelines including documentation, ethical and legal issues, decision-makers and involvement of others in DNACPR decisions as well as practical considerations such as validity, review and portability of decisions. Results: Policies from 26 acute, 12 community and 10 ambulance service Trusts were reviewed. There was variation in terminology used (85% described documents as policies, 6% procedures and 8% guidelines). Only one quarter of Trusts used the recommended Resuscitation Council (UK) record form (or a modification of the form). There was variation in the terminology used which included DNAR, DNACPR, Not for CPR and AND (allow natural death). Accountability for DNACPR decisions rested with consultants at all acute Trusts and the most senior clinician at community Trusts. Most Trusts (74%) recommended discussion of decisions with a multidisciplinary team. Compliance with guidance requiring clinical staff to assess the patient for capacity and when to consult a lasting power of attorney or independent mental capacity advocate occurred less commonly. There was wide variation in the duration of time over which a DNACPR decision was considered valid as well as in the Trusts' approach to reviewing DNACPR decisions. The level of portability of DNACPR decisions between healthcare organisations was one of the greatest sources of variation. Conclusions: There is significant variation in the translation of the national DNACPR guidelines into English healthcare Trusts' DNACPR policies.