ICMR Consensus Guidelines on ‘Do Not Attempt Resuscitation’

The document is intended to facilitate the process of decision-making on DNAR, which that is respectful of patient's autonomy and is in the best interests of the patient by the treating physician(s) on a case-to-case basis (Figure).

There should be adequate opportunity, time and space to discuss with the patient and family in private and facilitate clear understanding of DNAR and its implications. Thus, it should be done in anticipation of an impending cardiorespiratory arrest, during the current hospitalization of the patient. This will allow better communication and understanding between the treating physician(s) and patient/surrogate(s)/caregiver.

Teamwork and good communication are of crucial importance in decision-making and the delivery of care.

Combined decision may be taken with the help of another physician, a psychologist or social worker or a counsellor or the hospital administrator, particularly in some settings, such as rural hospitals, where other types of personnel may not be available. This should be applicable in case the treating physician is unsure about the futility of CPR, or there is no consensus between the physician and the patient/surrogate. All such discussions must be noted in the patient's case records and the DNAR form.

While communicating, the treating physician(s) should explain that the patient would continue to be provided all treatments intended for potentially curable conditions or to reverse potentially reversible conditions and to provide supportive care. Moreover, DNAR does not mean withdrawal or withholding of other life-supporting treatments. The treating physician(s) should understand the social/cultural perspective of the patient.

DNAR forms should be available in the language understood by the patient/surrogate(s) and should be signed, timed and dated by patient/surrogate(s) and the treating physician(s). In case the patient/surrogate(s) does/do not sign the DNAR form, the same should be recorded.

Hospital administration should make efforts to sensitize their healthcare professionals on all issues related to DNAR.

Since CPR is a form of treatment to be provided by the treating physician the responsibility for the final decision regarding DNAR rests with the treating physician(s), which is taken in consultation with the patient/surrogate(s), empowered with the required information. Often the patient's relatives/surrogates may face an ethical dilemma to take the decision regarding DNAR. To provide them psychological support and help them overcome any feeling of guilt, the treating physician(s) should explain to them the futility of CPR and the harm it might cause to the patient.

In case of conflict of opinion, an independent second opinion from a qualified medical practitioner belonging to the relevant specialty may be sought by the treating physician/patient/surrogate(s) in a timely manner.

Any decision taken contrary to patient's expressed wishes should based on be robust criteria, accounted for and documented in the hospital records.

The resuscitation plans and completed DNAR forms should be easily accessible to all the medical professionals to respond appropriately in the event of cardiorespiratory arrest of the patient concerned.

It is recommended to attach a copy of the DNAR form to the patient's case records and to be integrated with the electronic health records, if available.

All the case reports along with the DNAR forms should be archived for future reference.