What is DNACPR and Why is it Relevant in Dentistry?

A few years ago, I presented at the British Society of Gerodontology about DNACPRs and their relevance to dentistry. Better late than never, I've decided to summarise what every dentists needs to know about these orders in this blog!

Example of a DNACPR form

What is a DNACPR or DNAR?

DNACPR stands for do not attempt cardiopulmonary resuscitation and is sometimes called DNAR (do not attempt resuscitation) or DNR. It means if a person's heart stops (cardiac arrest) or they stop breathing (respiratory arrest), that healthcare teams will not try to restart them. 

This order is usually made by the patient if they have capacity, or their healthcare team if they don't (for example they have dementia, learning disabilities or are unconscious), but doctors can instate DNACPRs in patients who have capacity who might not want to make a decision as well.  There is a standardised form teams fill in (see picture above),  although it might look differently in some trusts, and many trusts have implemented a ReSPECT form which involves more than just DNACPR status but other emergency care planning wishes. See video below. 

Patients and medical teams might choose to have or give a DNACPR if they believe that it wouldn't be in a person's best interest to prolong their life or cause further suffering at the end of someone's life. CPR success rates even with a person who was healthy prior to an arrest are not that high, with only 1 in 10 people surviving an out of hospital arrest and many who survive with have a life long disability as a result. 

Why is it Relevant in Dentistry?

In some settings, dentists and their teams will come across patients who have DNACPR orders - for example in domiciliary settings, in hospital or even in general practice when caring for older or unwell populations. 

It is important to have an understanding of whether your patients has a DNACPR and how that might impact your care. A DNACPR order only means that CPR is withheld, but other medical emergencies and treatment should be offered as normal. DNACPRs can also only be in place for short periods of time - for example an acute illness in hospital, but some patients with chronic or progressive conditions may have long standing orders so ensure you are familiar with your own patient's situation and ask for copies of documentation.

What do you do if your Patient has a DNACPR?

If one or your patients has a DNACPR get as much information as possible about their medical and social histories - is this a long standing DNACPR, how safe it is for you to treat them in your environment (for example if you're in primary care), actually how much dentistry does this person need? For example, if they are clearly very unwell or end of life care, considering palliative dentistry rather than lots of extractions/rehabilitation. 

You should have a discussion with the patient and their carers/family about what is they were to have an arrest during dental treatment and should the order be suspended or not - the likelihood is that for the majority of dentistry, it is unlikely that you would be put in a situation where you'd need to consider giving CPR or not; however, in some instances, such as considering a general anaesthetic for dental treatment, this situation would need to be discussed. It is likely this would be lead by an anaesthetic team, but the dental team should be aware that the conversation surrounding the DNACPR needs to be had. 

Ultimately, a DNACPR is not legally binding. So if you are ever unsure as a clinician, it would be safer to begin CPR and once further help has arrived such as paramedics or crash teams, the decision whether to withdraw the CPR can be made by them. Only if a patient has made an Advanced Decision to Refuse Treatment, is then a DNACPR legally binding. 

Although an emotive topic, these orders and advanced life decisions are important to be aware of in a dental setting so do not be afraid to ask the question! We even have the question on our medical history forms - but it is also important to follow this up and ask for documentation. 

Have you had any training or discussions surrounding DNACPR orders? Please leave them in the comments below.

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