DNAR's in First Aid

First Aid is a fantastic life skill that enables people to help others in an emergency situation and provide some simple treatments that can save lives. In some cases though, the casualty may already be dead. This is when we would usually start CPR and use a Defibrillator, if one is available.

I always make it clear to my learners that we do CPR on dead people and that we are trying to bring them back from the dead. I believe this helps them to understand the reality of the situation and why survival rates are likely to be very low in the majority of cases.

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A question that seems to be coming up more and more, is what role a DNAR (Do Not Attempt Resuscitation) would have in the first aiders decision making, and any likely consequences of those decisions.

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I have been delivering first aid training in elderly care homes for several years, and have discussions regarding DNAR’s on an almost weekly basis. This subject has also been raised several times on various social media sites for first aid trainers, so I have put together this summary of my approach to the subject and some useful references and sources of further information. I will be using the term DNAR throughout, but the instruction ‘not to attempt resuscitation’ can be packaged in many different ways; DNACPR, ReSPECT forms, ADRT etc.

The short answer of course is that this is not an issue for first aiders to concern themselves with. They would not be expected to know if a casualty had a valid DNAR or understand the implications if they do have one, so the correct thing for them to do, is act as if it didn’t exist. This is usually only something that would be important for hospital or care staff, who should know who has a DNAR and what action to take in response.

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It is also worth highlighting that DNAR’s are not usually legal documents, but simply an expression of the persons wishes. If a first aider is unsure if a casualty is breathing normally, or whether or not a DNAR is present, the best course of action is to start CPR. I always highlight the two possible outcomes of this scenario; the casualty was dead and stays dead. Or, they were dead and are now alive. Why would you get in trouble for saving a life? Even if this was against their wishes, you have to remember that we live in a country (UK), where assisted suicide and euthanasia are illegal, so the law (Also see SARAH Act 2015) would protect a member of the public, or first aider, who prioritised life above preference. The level of expectation and accountability on first aiders is much lower than medical professionals such as doctors, nurses and paramedics.

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DNAR’s are also only applicable following a ‘natural’ death, such as passing away in their sleep. If they choked and then collapsed, not breathing, the DNAR would not apply and CPR should commence immediately. This is not why the DNAR was put in place and there is a much better chance of successful resuscitation than if they had a heart attack or cardiac arrest. CPR in this case, could be viewed as part of the treatment for choking, rather than a separate procedure.

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I often answer questions about DNAR’s by widening the conversation and discussing when it would be appropriate for a first aider NOT to do CPR. If the casualty had been decapitated, or their chest crushed under a heavy object, would you do CPR? No, neither would I!

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This is an extreme example, but helps to make the point that the decision is not a simple ‘Yes’ or ‘No’, but rather a weighing up of the available information and the likelihood of a positive outcome. The footballer Christian Eriksen, had a cardiac arrest during a Euro 2020 match (In June 2021 – the tournament was delayed due to COVID!) and was successfully revived after a single shock from a defibrillator. He survived thanks to the swift actions of those around him, but his chances were helped by the fact that he was young, very fit and his ‘only’ problem was an electrical fault with his heart, which the defibrillator was able to rectify.

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If you compare this with my own father, who is 70 years old, overweight, has severe asthma, COPD and angina, amongst other health problems, AND, who happens to have a DNAR. If I were to find him one day, unresponsive and not breathing, would it be appropriate for me to do CPR? Even if I witnessed his death, my chances of reviving him would be extremely slim and there are likely to be health complications.

DNAR’s are complicated and the subject has been put back in the spotlight during the recent coronavirus pandemic. It is something which many people will have strong opinions on and each case needs unique consideration of all of the information available. When DNAR’s are put in place, they (should) involve consultation with the person concerned and, where appropriate, their family.

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It is not something that first aiders should worry about, but I do believe that first aid trainers should be able to offer informed and considerate feedback when the subject is raised. Simply dismissing it as not important, doesn’t alleviate the concern of those asking the question.

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There are a number of sources of further information below that might help further your understanding of this subject.

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Further reading;

Guidance from the British Medical Association, Resuscitation Council UK, and the Royal College of Nursing (previously known as the "Joint Statement") - https://www.resus.org.uk/library/publications/publication-decisions-relating-cardiopulmonary

Interesting article from an American doctor - https://www.newyorker.com/news/the-weekend-essay/the-hidden-harms-of-cpr

Article demonstrating the importance of advanced decisions - https://metro.co.uk/2019/07/28/people-are-missing-out-on-their-perfect-death-because-doctors-do-not-know-their-wishes-10354232/

NHS information on Advanced Decisions/ Living Wills - https://www.nhs.uk/conditions/end-of-life-care/planning-ahead/advance-decision-to-refuse-treatment/

DNAR incorrectly applied when a care home resident choked - https://www.bbc.co.uk/news/uk-65597888