Stroke Training and Awareness Resources (STARs)

Discussing Cardio Pulmonary Resuscitation (CPR)

  • Consider discussing CPR status after discussing that the patient is so ill that they may be at risk of dying imminently.
  • Be mindful that family members may be distressed and therefore need time to process bad news and may require emotional support
  • Go on an explain that if a person has had a severe stroke and they are very unwell, it is possible that their breathing and heart may stop. In this circumstance, using chest compressions or electricity to restart their heart (CPR) may not be successful or be in the best interest of the patient.
  • Reinforce that the team will ensure that the person is comfortable and well cared for when they are dying
  • Explain that we complete a special form to let all the staff know about the CPR decision as part of the person’s individual care plan.

The decision-making framework:

CPR flowchart: see view text alternative button for details

  1. Is cardiac or respiratory arrest a clear possibility for the patient? If yes, go to 3; if no, go to 2.
  2. It is not necessary to discuss CPR with the patient unless they express a wish to discuss it. End here.
  3. Is there a realistic chance that CPR could be successful? If yes, go to 5; if no, go to 4.
  4. If a DNACPR decision is made on clear clinical grounds that CPR would not be successful there should be a presumption in favour of informing the patient of the decision and explaining the reason for it (see section 5). Those close to the patient should also be informed and offered explanation, unless a patient’s wish for confidentiality prevents this.Where a patient lacks capacity and has a welfare attorney or court-appointed deputy or guardian, this representative should be informed of the decision not to attempt CPR and the reasons for it, as part of the ongoing discussion about the patient’s care.
    Where a patient lacks capacity, the decision should be explained to those close to the patient without delay. If this is not done immediately, the reasons why it was not practicable or appropriate must be documented (see section 5).
    If the decision is not accepted by the patient, their representative or those close to them, a second opinion should be offered. End here.
  5. Does the patient lack capacity AND have an advance decision specifically refusing CPR
    OR have an appointed attorney, deputy or guardian? If yes, go to 6; if no, go to 7.
  6. If a patient has made an advance decision refusing CPR, and the criteria for applicability and validity are met, this must be respected.If an attorney, deputy or guardian has been appointed they must be consulted (see sections 9.1 and 10). End here.
  7. Does the patient lack capacity? If yes, go to 8; if no, go to 9.
  8. Discussion with those close to the patient must be used to guide a decision in the patient’s best interests (see section 10). When the patient is a child or young person, those with parental responsibility should be involved in the decision where appropriate, unless the child objects (see section 11). End here.
  9. Is the patient willing to discuss his/her wishes regarding CPR? If yes, go to 11; if no, go to 10.
  10. Respect and document their refusal (see section 6.3). Discussion with those close to the patient may be used to guide a decision in the
    patient’s best interests, unless confidentiality restrictions prevent this. End here.
  11. The patient must be involved in deciding whether or not CPR will be attempted in the event of cardiorespiratory arrest. End here.
  • If cardiorespiratory arrest occurs in the absence of a recorded decision there should be an initial presumption in favour of attempting CPR.
  • Anticipatory decisions about CPR are an important part of high-quality health care for people at risk of death or cardiorespiratory arrest.
  • Decisions about CPR are sensitive and complex and should be undertaken by experienced members of the healthcare team with appropriate competence.
  • Decisions about CPR require sensitive and effective communication with patients and those close to patients.
  • Decisions about CPR must be documented fully and carefully.
  • Decisions should be reviewed with appropriate frequency and when circumstances change.
  • Advice should be sought if there is uncertainty.

Page last reviewed: 16 Jan 2023