Do not attempt CPR orders

In Ireland, there is a presumption that CPR will be provided in the event of cardiac arrest. However, CPR will be withheld if there is an advance decision by a patient to refuse CPR or a decision by a healthcare professional to withhold CPR. This decision can be documented in a DNACPR order.

Current context in Ireland

There is currently no specific legislation or standalone national policy governing the use of DNACPR orders in Ireland. Rather, DNACPR orders, and the decisions to withhold or refuse CPR which underpin them, are guided by a broader legal and policy framework.

These orders engage the rights of patients to autonomy, bodily integrity, and human dignity which are safeguarded under the Irish Constitution and the European Convention on Human Rights. Further, in Ireland, a patient can refuse treatment, including life-saving treatment such as CPR, and under the Assisted Decision-Making (Capacity) Act 2015 (hereafter the 2015 Act), patients can document their refusal of CPR in an ‘advance healthcare directive’. Where a patient does not have capacity to make a decision about CPR or his/her capacity is in question, there are guiding principles set out in the 2015 Act that should be applied by healthcare professionals.

The HSE’s National Consent Policy (2022) provides some guidance in relation to DNACPR orders. This policy is a broader policy focused on consent. However, Part Three of the policy (with supplementary guidance in Appendix 10) focuses on decisions to not resuscitate and provides guidance regarding:

• the general principles that apply to DNACPR decisions;
• the circumstances when DNACPR decisions should be considered;
• balancing the benefits and risks of providing CPR.

The policy advises healthcare practitioners to document DNACPR orders clearly and accurately in patients’ healthcare records. However, a standardised DNACPR order form is not included in the policy.

Need for a national approach

While there is a broader legal and policy framework in Ireland that can be applied to DNACPR orders, DNACPR order practice in Ireland is not governed by a standalone DNACPR policy that is required to be applied nationally. As a result, it has been possible for different policy approaches to DNACPR orders and different ways of documenting DNACPR decisions to develop at a local and regional level.

Research on DNACPR orders in Ireland indicates that there may be a level of confusion and uncertainty surrounding DNACPR orders in practice. A number of studies suggest that some healthcare practitioners in Ireland do not have a clear understanding regarding:

• DNACPR orders and the treatment that these orders apply to; and
• the role of practitioners and next of kin in resuscitation decision-making.

In practice, some healthcare practitioners may misinterpret what a DNACPR order means for the broader care that is provided to a patient with a DNACPR order and this misperception may have important implications for the treatment of patients. Research indicates that some healthcare practitioners may incorrectly believe that a patient with a DNACPR order in place cannot receive other treatment, such as antibiotics or physiotherapy, or that he/she cannot be transferred from a nursing home to a hospital if he/she has a DNACPR order in place. Patients may be under-treated as a result of a DNACPR order being in place.

The development of a national DNACPR policy and form would ensure that there is clarity and consistency in Irish DNACPR order practice. It is understood that a new HSE policy is forthcoming, which will be informed by a research project commissioned from the University of Limerick.

Learning from Wales

In developing a national policy approach, Ireland can learn from other jurisdictions. In Wales, for example, an All Wales Policy for DNACPR for Adults has been in place since February 2015.

Figure 1 provides an overview of this policy, including its development, implementation, and a summary of some of its key features.

The Welsh national DNACPR policy and form has been tested and reviewed for almost a decade. This policy approach may offer some learnings from an Irish perspective with regards to:

• policy development and implementation, including the stages of stakeholder engagement and evaluation that underpin the development of a robust DNACPR policy;
• policy content and design, including the development of a decision-making framework diagram for healthcare practitioners to follow when implementing the policy in practice;
• audit and review procedures, including the insertion of key audit points throughout the policy and the requirement for reviews every two years.

A Comparator for DNACPR Policy Development – Wales

Levers for change

New developments in law may provide Irish policymakers and legislators with an opportunity to shape how the DNACPR order system will operate into the future. As it would be the first national DNACPR order system, there is a chance to develop and implement it so that it will operate as part of the forthcoming move towards electronic health records in Ireland and the European Union. This would be in line with the Health Information Bill 2024 and the European Health Data Space Regulation.

The Health Information Bill 2024 sought to provide for electronic health records in Ireland. It completed Second Stage in Dáil Éireann but fell with the dissolution of the 33rd Dáil. The Bill did not provide for DNACPR orders. However, if it is restored to the Order Paper of the new parliament, Members could seek to amend it to include DNACPR orders and decisions about resuscitation into the electronic health record system. Alternatively, this could be provided for by the Minister for Health through regulations.