Resuscitation decisions, explained properly

A decision about cardiopulmonary resuscitation is one of the most common medical decisions discussed at the end of life, and it is surrounded by misunderstanding.

What CPR actually is and does

Cardiopulmonary resuscitation is an attempt to restart the heart and breathing after they have stopped. It involves chest compressions, usually ventilation, sometimes electric shocks and drugs.

Survival rates are considerably lower than most people believe.

Public perception is substantially shaped by television, where depicted survival rates are far higher than reality. Studies comparing televised outcomes with actual outcomes have found large discrepancies.

In reality, survival to hospital discharge after in-hospital cardiac arrest is a minority outcome, and it is considerably lower in people who are frail, who have advanced illness, or who have multiple conditions.

For someone dying of an advanced progressive illness, the chance of CPR restoring them to their previous state approaches zero, because the arrest is the end of the illness rather than a discrete event.

CPR also causes injury — rib fractures are common — and where it succeeds partially, it may result in survival with severe brain injury.

What a DNR decision means

It means that if the heart stops, CPR will not be attempted.

It means nothing else.

This is the misunderstanding that causes the most harm. Families frequently believe, and staff occasionally act as though, a resuscitation decision means withdrawing other care.

It does not. A person with a DNR decision continues to receive all other treatment — antibiotics, fluids, oxygen, pain relief, surgery, intensive care if appropriate.

Studies have found that patients with resuscitation decisions in place sometimes receive less of other treatment, which is a recognised problem and is not what the decision means.

If you have concerns that care is being reduced, say so directly.

Who makes the decision

This varies by jurisdiction and the general position is that it is a clinical decision, made in discussion with the patient or those close to them.

Where CPR would not work — where it would not restart the heart, or would not achieve any benefit — clinicians are generally not obliged to attempt it, and in many systems are not obliged to offer it.

There is however a strong expectation in many jurisdictions that the decision is discussed with the patient or their representative, and case law in several countries has established that failing to consult is unlawful in certain circumstances.

A patient with capacity can refuse CPR, and that refusal should be respected. A patient cannot generally demand CPR that clinicians consider futile.

The conversation

Frequently handled badly, in both directions.

The bad version: a form presented for signature, framed as a choice about whether the family wants their relative to be "allowed to die", with no explanation of what CPR involves or what the realistic outcome would be.

The better version: an explanation of the person's condition, what would happen if the heart stopped, what CPR would and would not achieve for this person, and what the plan is for care.

Questions worth asking:

What would CPR realistically achieve for this person?

What is the chance of survival, and of survival to a state they would find acceptable?

What will continue to be done?

Is this decision recorded, and does it apply everywhere or only here?

Can it be reviewed?

The burden families carry

Framing the decision as the family's choice causes real and lasting harm.

Families who believe they authorised a death carry guilt for years, even where the decision was clinically inevitable and their agreement was, in substance, being informed.

The better framing, and the one good clinicians use: this is a clinical judgement about what would work, and we are explaining it to you, not asking you to decide whether your father lives.

If you are being asked to decide and it feels like an impossible weight, it is reasonable to ask: "Are you asking me to make this decision, or telling me what you recommend?"

Portable and broader forms

Several health systems now use forms recording a broader set of recommendations — not only CPR, but preferences about hospital admission, intensive care and other interventions — designed to travel with the person between settings.

These are generally more useful than a standalone resuscitation decision, because they record the shape of care rather than a single negative.

If such a form exists where you live, it is worth asking about.

Recording it in advance

A resuscitation decision made in a hospital applies in that setting, and may not follow the person home.

Anyone who wants their wishes about CPR to be known should record them in an advance directive, tell their GP so that it is in their records, tell their proxy, and ask whether a portable form is available.

Without this, an ambulance called in an emergency will begin CPR, because that is the default in the absence of information.

That is a common and distressing scenario at home deaths, and it is preventable by having the paperwork where the paramedics will find it.

The thing worth saying

A decision not to attempt CPR is not a decision to stop caring for someone. It is a recognition that a particular intervention would not help.

Framed accurately, most families find it a relief rather than a burden — because what they are frightened of is their relative dying badly, and CPR at the end of a terminal illness is a bad death rather than a rescue.

This is general information. Law and practice regarding resuscitation decisions differ by jurisdiction. Discuss with the treating clinical team and ask for the decision and the reasoning to be explained.