Navigating DNACPR decisions: a qualitative study of DNACPR factor variability and implementation among NHS Doctors

TL;DR

This study explores how NHS doctors make DNACPR decisions, highlighting variability in their approaches and the need for clearer guidance.

Contribution

The study reveals how clinicians use personal strategies and professional autonomy in DNACPR decisions due to the lack of national policy.

Findings

Doctors consider factors like age, frailty, quality of life, and perceived outcome when making DNACPR decisions.

Variability in decision-making arises from the absence of standardized guidance, leading to reliance on individual judgment.

A national DNACPR policy integrating evidence-based data could help standardize decisions while allowing clinical autonomy.

Abstract

The ongoing absence of a national Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policy means that there remains a lack of explicit guidance on how clinicians should select, measure and assess relevant factors when deciding whether to implement a DNACPR order. Although previous studies have raised this as a concern, this qualitative study explores the extent to which individual clinicians not only adopt personal strategies to assess patients, but also value having a degree of professional autonomy when making DNACPR decisions.

Sixteen semi-structured interviews were conducted with National Health Service (NHS) clinicians via video calls. Participants were recruited via snowball sampling. Thematic analysis was conducted using an inductive approach. Initial codes were generated from the interview transcripts, which were then organised into overarching themes based on patterns and relationships identified across the coded data.

Four main groupings summarise the different considerations adopted by doctors when making DNACPR decisions: age, frailty, assessment of quality of life, and perceived outcome. However, whilst the same general areas for consideration were drawn on, the participating doctors nevertheless assessed them differently and often prioritised them in different ways. In the absence of explicit, standardised guidance for weighting these factors, decisions were often made on the basis of individual judgement and local convention.

This study demonstrates that physician-level variation in DNACPR decision-making reflects the inherent tension clinicians experience when balancing individual patient needs with the absence of explicit, standardised guidance. The ability to make decisions on a case-by-case basis, with the freedom to weigh diverse factors in a nuanced way is an important aspect of clinical decision-making. However, this can lead to inadvertent bias if decisions are based on factors not necessarily supported by established evidence.

Our findings highlight a clear need for a more robust and equitable framework for these critical conversations, whilst also enabling clinicians to be able to make case-by-case decisions. The development of a national DNAPR policy that integrates evidence-based data may help doctors select and weigh factors appropriately, and provide a framework for the initiation of DNACPR discussions. However, such a policy must nevertheless be sufficiently flexible to permit doctors the autonomy required to make nuanced decisions on the basis of a range of patient-specific contextual assessments. Our key recommendation, therefore, is that clinicians should be supported not only by improved procedures and processes, but also by confidence that their professional judgement is rooted in the most current clinical evidence.

The online version contains supplementary material available at 10.1186/s12910-025-01286-2.