title: Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation.
abstract: Most people who die in hospital do so with a DNACPR order in place, these orders are the focus of considerable debate.
  
  
  OBJECTIVE
  To identify factors, facilitators and barriers involved in DNACPR decision-making and implementation.
  
  
  METHODS
  All study designs and interventions were eligible for inclusion. Studies were appraised guided by CASP tools. A qualitative analysis was undertaken.
  
  
  METHODS
  Included electronic databases: Medline, Embase, ASSIA, Cochrane library, CINAHL, PsycINFO, Web of Science, the King's Fund Library and scanning reference lists of included studies.
  
  
  RESULTS
  Four key themes were identified: Considering the decision - by senior physicians, nursing staff, patients and relatives. Key triggers included older age, co-morbidities, adverse prognostic factors, quality of life and the likelihood of success of CPR. Discussing the decision - levels, and combinations, of physician and nursing skills, patient understanding and family involvement produced various outcomes. Implementing the decision - the lack of clear documentation resulted in a breakdown in communications within health teams. Staff knowledge and support of guidelines and local policies varied. Consequences of a DNACPR decision - inadequate understanding by staff resulted in suboptimal care, and incorrect withdrawal of treatment.
  
  
  CONCLUSIONS
  Significant variability was identified in DNACPR decision-making and implementation. The evidence base is weak but the absence of evidence does not indicate an absence of good practice. Issues are complex, and dependent on a number of factors. Misunderstandings and poor discussions can be overcome such as with an overall care plan to facilitate discussions and reduce negative impact of DNACPR orders on aspects of patient care.
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.
authors.forename: Carole
authors.initials: C
authors.lastname: Mockford
authors.affiliation: Division of Health Sciences, University of Warwick, United Kingdom; Cambridge University Hospitals, NHS Foundation Trust, Box 148, CUH NHS FT, Hills Road, Cambridge CB2 0QQ, United Kingdom.
authors.forename: Zoë
authors.initials: Z
authors.lastname: Fritz
authors.affiliation: Cicely Saunders Institute, Kings College London, United Kingdom; Palliative Care Guy's and St Thomas' Hospitals NHS Foundation Trust, Great Maze Pond SE1 7RT, United Kingdom.
authors.forename: Rob
authors.initials: R
authors.lastname: George
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.
authors.forename: Rachel
authors.initials: R
authors.lastname: Court
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.
authors.forename: Amy
authors.initials: A
authors.lastname: Grove
authors.affiliation: Glasgow Medical School, University of Glasgow, Glasgow G12 8QQ, United Kingdom.
authors.forename: Ben
authors.initials: B
authors.lastname: Clarke
authors.affiliation: Division of Health Sciences, University of Warwick, United Kingdom; Heart of England, NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom.
authors.forename: Richard
authors.initials: R
authors.lastname: Field
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom; Heart of England, NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom.
authors.forename: Gavin D
authors.initials: GD
authors.lastname: Perkins
mesh_terms: D016887:Cardiopulmonary Resuscitation / Q000592:standards*; D003657:Decision Making; D006801:Humans; D016414:Resuscitation Orders
keywords: DNACPR orders; Decision-making; Implementation; Systematic review