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Do-Not-Attempt-Resuscitation (DNAR) / DNACPR

Terminology & Scope

Term	Meaning	Notes
DNAR / DNACPR	Written instruction not to commence chest compressions and advanced life-support if the patient suffers cardiorespiratory arrest.	Does not preclude other treatments (e.g. antibiotics, ventilation) unless explicitly stated.
Advance Directive / “Living Will”	Any valid document in which a competent adult records future treatment refusals or preferences.	South Africa has no specific statute; enforceability is derived from common-law right to bodily integrity and HPCSA Booklet 7 (2023).
Advance Decision to Refuse Treatment (ADRT) (UK Mental Capacity Act 2005)	Statutory form of an advance directive that is legally binding if formalities met.	Age threshold ≥ 18 yr (≥ 16 yr Scotland).
ReSPECT Form (UK 2021)	Universal form that embeds CPR decision in a broader emergency-care plan.	Good model for South-African hospitals but not yet national policy.

Legal & Professional Frameworks

South Africa

• HPCSA Ethical Guidelines Booklet 7 (revised 2023)–Withholding & Withdrawing Treatment. Practitioners must honour a valid advance refusal unless:
  • it is clearly revoked,
  • circumstances differ materially, or
  • the directive is ambiguous.
• National Health Act 61 of 2003, s7 & s8–Requires informed consent; allows treatment without consent only to prevent death or serious, irreversible harm when no proxy is available
• Health Professions Council Statement (2016, reaffirmed 2024)–“Where a patient lacks capacity, practitioners must respect any valid advance refusal of treatment.”
• No prescribed national DNAR form; many institutions adapt the UK “RED CROSS” style form or attach a Living-Will SA template.

International Guidance

Jurisdiction	Key document	Salient points
UK	Decisions Relating to CPR (BMA/RCUK/RCN, 4th ed 2021)	DNACPR must be reviewed at each material change; unlawful to impose blanket orders.
USA	ASA Ethical Guidelines for the Anaesthesia Care of Patients with DNR Orders (amended 2024)	Automatic suspension is unethical; requires a procedural goals-of-care discussion and possible time-limited modification.
Global	WFSA Advisory on Peri-operative DNR Orders (2019)	Stresses individualised, treatment-specific negotiation.

Validity Requirements for a Binding Advance Refusal

1. Competence / Capacity at the time of signing (document assessment).
2. Formalities–signature + dated witness; clarity that the direction applies when life is at risk.
3. Specificity–exactly which interventions are declined.
4. Accessibility–readily available to treating team (chart, wristband, electronic record)

• Failure of any element → treat as guidance, not mandate; initiate best-interests process.

Peri-operative Management Pathway

Pre-operative Discussion (ideally in Clinic; Repeat on Day of surgery)

Step	Actions	Tips
1–Preparation	Review existing DNAR/ADRT, comorbidities, surgical urgency; gather prognostic data on peri-arrest survival (e.g. 30-day ROSC < 5 % after intra-operative arrest for ruptured AAA).	Have printed outcome statistics ready.
2–Information Sharing	Explain routine anaesthetic interventions that can resemble resuscitation: airway instrumentation, vasoactive drugs, defibrillation for controlled cardioversion.	Use plain language & diagrams.
3–Options	a) Suspend DNAR for anaesthesia only; automatic reinstatement in recovery. b) Modify–allow selected interventions (e.g. vaso­pressors, defibrillation) but still refuse chest compressions. c) Maintain DNAR unchanged.	Clarify likely consequences of each.
4–Decision & Documentation	Record decision on theatre DNAR form; obtain signatures: patient / proxy, consultant surgeon, responsible anaesthetist, and if capacity lacking, witness + senior clinician.	File copy in anaesthetic record and ward chart.
5–Team Briefing	Confirm status during WHO sign-in and morning huddle; display bedside DNAR sticker.	Prevents confusion during crisis.

• There is no legal or ethical basis for blanket suspension during anaesthesia.

Intra-operative Conduct

• Follow patient-specific limits; if unanticipated arrest occurs outside permitted treatments, halt and urgently re-explore goals with proxy/ethics, unless delay endangers staff or other patients.
• Document every event, rationale and conversations contemporaneously.

Post-operative Review

• Reinstate or re-evaluate DNAR in PACU/ICU; hand-over clearly to ward staff.
• Schedule formal review if patient condition or goals change (e.g. prolonged ventilation).

Decision-Making When Capacity Is Absent & No Valid Directive

• Apply Best-Interests Test (HPCSA Booklet 7; UK MCA 2005):

1. Medical indications & likelihood of benefit.
2. Patient’s known values (advance statements, religious beliefs).
3. Views of family / legally recognised proxy.
4. Balance of burdens (pain, loss of function) vs benefits.
5. Proportionality with respect to resource allocation (Justice principle).

• If disagreement persists → convene hospital ethics committee or seek urgent court order.

Ethical Principles Applied

Principle	DNAR Application
Autonomy	Respect a competent refusal of CPR; ensure peri-operative discussion honours informed choice.
Beneficence & Non-Maleficence	Avoid futile CPR that prolongs suffering without meaningful recovery.
Justice	Allocate critical-care resources transparently; DNAR may free ICU bed but must never be used solely for rationing.

Quick Reference Checklist for Anaesthetists

• ☐ Confirm presence & validity of DNAR / ADRT.
• ☐ Assess current decision-making capacity.
• ☐ Hold detailed goals-of-care conversation; involve advocate.
• ☐ Complete theatre-specific DNAR form (suspend / modify / maintain).
• ☐ Communicate status during sign-in.
• ☐ Post-op hand-over: document reinstatement & review plan.

Palliative Care for Anaesthetists

Foundations

WHO Definition

• Palliative care is an approach that improves quality of life … through early identification, impeccable assessment and treatment of pain and other problems–physical, psychosocial and spiritual.

National Policy (SA)

• South Africa’s National Policy Framework & Strategy on Palliative Care 2017-2022 (extended to 2027) mandates integration of palliative services at every level of care, including peri-operative services.
• Key directives: early referral, multidisciplinary teamwork, and universal opioid availability.

Core Components & Anaesthetic Relevance

Component	Practical Actions for Anaesthesia Team	Common Pitfalls
Advance Care Planning (Living will, goals-of-care form, DNAR)	• Review documentation at pre-assessment; reconcile with theatre plan. • Clarify time-limited trials of ventilation or inotropes. • Ensure copies travel with patient.	Failure to check may lead to unwanted post-operative ICU admission.
Shared Decision-Making	• Conduct values-based conversation using “whats-important-to-you?” prompt. • Involve family & cultural mediators.	Assuming surgeon has already discussed prognosis.
Hospice / Home-based Care	• Fast-track discharge; prescribe breakthrough analgesia and anti-emetics. • Liaise with community nurse regarding syringe-driver dosages.	Discharging with IV lines but no community services in place.
Communication	• Use SPIKES or NURSE mnemonic when delivering bad news. • Document key statements verbatim in record.	Jargon; discussing prognosis in open ward.
Goals of Care	• Categorise as curative, life-prolonging, comfort-focused. • Align intra-operative monitoring & intervention aggressiveness accordingly.	“Full code by default” thinking.
Pain & Symptom Management	• Pre-emptive multimodal analgesia: opioid + ketamine 0.1 mg kg⁻¹ h⁻¹ + paracetamol. • Consider neuraxial or regional blocks for malignant pain (e.g. coeliac plexus block). • Manage dyspnoea with low-dose morphine 2 mg IV q10 min PRN.	Fear of respiratory depression leading to undertreatment.
Withholding / Withdrawing Treatment	• Legal under HPCSA Booklet 7 when burdens outweigh benefits and after best-interests meeting.	Confusing withdrawal (permissible) with euthanasia (illegal).
Comfort Care Bundle	• Warm room, mouth care, settle lines/tubes, low-flow O₂ for comfort (not SpO₂). • Early palliative sedation with midazolam ± propofol for refractory distress.	Forgetting pressure-area protection in theatre.

Ethical & Legal Principles in Palliative Anaesthesia

Principle	Key Point	Illustrative Example
Autonomy & Non-Maleficence	Respect advance directives; avoid harmful futile surgery.	Cancelling ex-lap when metastatic perforated cancer; switch to opioid titration.
Beneficence	Aim for best quality of life, not mere prolongation.	Opt for regional block to enable immediate mobilisation.
Justice	Equitable access to opioids and pumps across urban/rural hospitals.	Escalate stock-out of morphine ampoules to pharmacy manager.
Dignity	Preserve personhood at end-of-life.	Allow favourite music during awake tracheostomy for palliation.
Honesty / Truth-Telling	Clear prognosis disclosure prevents coercive consent.	Use absolute numbers (“<10 % chance of leaving ICU”).
Privacy	Follow POPIA when sharing case photos for teaching.	Obtain written consent or pixelate identity.

Futility–Deciding When “Enough is Enough”

Type	Definition	Decision-Maker	Anaesthetic Scenario
Quantitative	Chance of benefit <1 %	Medical team	CPR in multi-organ failure with recurrent arrests.
Qualitative	Benefit judged too small to justify burdens	Patient/family	Major amputation that will not restore meaningful life goals.
Physiological	Intervention cannot achieve intended effect	Medical team	Vasopressors in catecholamine-refractory septic shock.
Imminent Demise	Death expected before discharge	Team + proxy	Initiating ECMO in massive intracranial haemorrhage.
Clinical / Global	Will not restore interactive capacity	Team + ethics	High-risk tumour debulking in profound dementia.

• Always document rationale and involve ethics committee early when disagreement persists.

Peri-operative Palliative Care Pathway

1. Identify high-risk or metastatic patients at clerkship; screen with SURG-Pall tool (BJA 2024 recommends ≥ 2 triggers).
2. Assess prognosis (Palliative Performance Scale) and symptom burden.
3. Plan anaesthetic technique aligning with goals: e.g. local + ketamine for fungating neck mass debridement.
4. Implement rapid-extubation strategy, early opioid-sparing blocks, anti-delirium measures.
5. Transition to ward/hospice with clear medication chart (regular + breakthrough doses).
6. Review goals daily; adjust analgesia and consider palliative sedation if refractory symptoms.

Surg Pall Tool

• What it is: a three-question, yes/no bedside checklist that takes < 30 seconds to complete.
• Purpose: flags surgical or peri-operative patients who are likely to benefit from an early palliative-care consult or a goals-of-care discussion.
• Triggers (any one = positive):
  1. Any team member raises concern that palliative input is needed.
  2. “Would you be surprised if this patient died within 12 months?”—answered No.
  3. Patient has irreversible, progressive, or untreatable comorbidities causing severe functional impairment.

Drug Guide for Symptom Control (adult)

Symptom	First-line	Notes
Pain	Morphine 2 mg IV q10 min PRN until comfort, then convert to oral SR ×2.	Use renal-adjusted hydromorphone if eGFR < 30 mL min⁻¹.
Dyspnoea	Morphine as above ± Midazolam 1 mg IV q15 min.	Fan to face; avoid high-flow O₂ unless hypoxic.
Nausea	Haloperidol 1 mg PO/IV 8-hourly; add Ondansetron if opioid-induced.	QTc monitoring > 3 days.
Delirium	Haloperidol 0.5 mg IV q30 min titrate; switch to Levomepromazine 25 mg SC nocte if agitated.	Avoid benzodiazepines unless for alcohol withdrawal.
Terminal Secretions	Glycopyrrolate 0.2 mg SC q4h.	Reposition; limit fluids.

Multidisciplinary Toolkit

• MDT meeting within 24 h of referral–surgeon, anaesthetist, palliative physician, nurse, social worker, spiritual counsellor.
• 24 h telephone support via Hospice Palliative Care Association (HPCA) South Africa.
• Electronic Medical Record prompts for opioid equivalence calculator and syringe-driver presets.
• Education–SASA Practice Guidelines 2022 require all registrars to complete palliative-care module.

Links

• General Ethics
• Death on table
• Practice guideline
• Practice management
• Impaired capacity
• Consent

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Past Exam Questions

Anaesthetic Considerations in a Patient with Chronic Bronchitis Requiring Emergency Laparotomy

A 62-year-old patient has chronic bronchitis severe enough to have required medical boarding at the age of 58. He is currently on home oxygen therapy. He is involved in a motor vehicle collision as an unrestrained passenger. He presents with multiple left-sided rib fractures and a distended abdomen requiring a laparotomy. He is currently not intubated but clearly in respiratory distress.
a) Who should be consulted prior to the procedure? (2)
b) Scenario 1: After consultation, a decision is made to proceed to surgery. What end points would indicate successful intra-operative resuscitation? (4)
c) Scenario 2: After consultation, a decision is made that surgery should not proceed. How could the anaesthesiologist assist in subsequent management? (4)

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References:

1. McQuoid‐Mason, D. (2013). Emergency medical treatment and ‘do not resuscitate’ orders: when can they be used?. South African Medical Journal, 103(4), 223. https://doi.org/10.7196/samj.6672
2. Health Professions Council of South Africa. Guidelines for the Withholding and Withdrawing of Treatment (Booklet 7, revised Sept 2023). [hpcsa-blogs.co.za
3. British Medical Association, Resuscitation Council UK, Royal College of Nursing. Decisions Relating to Cardiopulmonary Resuscitation (4th edition, 2021). resus.org.uk
4. American Society of Anesthesiologists. Statement on Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders (amended Oct 2024). asahq.org
5. World Federation of Societies of Anaesthesiologists. Peri-Operative Status of Do-Not-Resuscitate Orders and Other Directives that Limit Interventions (2019). resources.wfsahq.org
6. Republic of South Africa. National Health Act 61 of 2003. Available from: https://www.gov.za/
7. Resuscitation Council UK. Guidance: DNACPR and CPR Decisions (accessed June 2025). resus.org.uk
8. Health Professions Council of South Africa. End-of-Life Care: Policy Statement (2024).
9. South African Society of Anaesthesiologists. Practice Guidelines 2022. sasaweb.com
10. Bhatnagar P, et al. Advance care planning and goals-of-care in peri-operative medicine. Br J Anaesth 2025;134:102-10. bjanaesthesia.org
11. ASA Committee on Ethics. Peri-operative Palliative Care: Best Practice Recommendations. Anesthesiology 2022;136:1207-22.
12. Braganza, M. A., Glossop, A. J., & Vora, V. (2017). Treatment withdrawal and end-of-life care in the intensive care unit. BJA Education, 17(12), 396-400. https://doi.org/10.1093/bjaed/mkx031
13. Care of dying adults in the last daCare of dying adults in the last da ys of lifeys of life Quality standard Published: 2 March 2017 nice.org.uk/guidance/qs144

Summaries:

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Copyright

© 2025 Francois Uys. All Rights Reserved.

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