This question comes from ‘… a community support worker I am caring for a patient who has a “Do Not Resuscitate” order’. They ask
If this client becomes unconscious what should I do?
Start CPR because I am not a medical professional and can’t make those decisions or just make client comfortably until ambulance arrives and handover the DNR document for them to decide?
Just wondering if there is a straight forward answer to a DNR.
There is a ‘straight forward answer’ and what is worrying is that a person who is working as a ‘community support worker’ hasn’t been trained by their agency on how to deal with this matter.
First let me say that I am assuming that the DNR documentation has been seen and it should be copied into the client file. I’m also assuming that the DNR documentation has been signed off with at least the knowledge of the client’s family.
Where a person needs CPR, the legal justification is necessity – see The Doctrine Of Necessity – Explained (January 31, 2017). The relevant quote, taken from the case law, is the quote from Lord Goff in In Re F  2 AC 1:
The basic requirements, applicable in these cases of necessity, that, to fall within the principle, not only (1) must there be a necessity to act when it is not practicable to communicate with the assisted person, but also (2) the action taken must be such as a reasonable person would in all the circumstance take, acting in the best interests of the assisted person.
On this statement of principle, I wish to observe that officious intervention cannot be justified by the principle of necessity. So intervention cannot be justified when another more appropriate person is available and willing to act; nor can it be justified when it is contrary to the known wishes of the assisted person, to the extent that he is capable of rationally forming such a wish.
Where there is DNR documentation completed with the client’s consent, CPR can’t be justified. We usually think CPR is in the patient’s best interests and someone who has suffered a sudden cardiac arrest would rather live than die. A person who is approaching the end of their life has to face that reality and may have decided that given the underlying conditions – whether it’s a terminal illness or just the manifestation of old age – that CPR is not in their best interests. If that is the case and they have recorded that in consultation with their doctor and family, we know that CPR is NOT in the patient’s best interests. In that case commencing CPR on a person who has gone to the effort of recording their wishes on a DNR document is NOT ‘action … a reasonable person would in all the circumstance take, acting in the best interests of the assisted person.’
Secondly, regardless of best wishes, if the person has indicated that they do not want CPR, then the treatment cannot be justified as it is ‘contrary to the known wishes of the assisted person’ (emphasis added).
DNR documentation can also be completed without the consent of the patient if the treatment will, given the person’s conditions, futile. There is no obligation to provide treatment that will not advance the patient’s best interests or achieve a therapeutic outcome (Airedale NHS Trust v Bland  A.C. 789].
If the patient is unable to give consent to the DNR order then it must be made by the medical team and family acting in the best interests of the person in need of care. Again, if that has been done and recorded, a care worker should not commence CPR as that is NOT ‘action … a reasonable person would in all the circumstance take, acting in the best interests of the assisted person.’
As a community care worker who honours DNR documentation you are not making decisions, you are giving effect to decisions that have already been made.
If you are not willing to honour a DNR decision, one has to ask ‘what is the purpose of consent in medical care?’ People are allowed to make decisions about their care even if it will lead to their death. If we are not willing to honour that, if we are going to assist that people receive treatment whether they want it or not, we are going back to paternalistic health care, or worse. What’s worse is that people provide care, like CPR, not because it is in the patient’s best interests but because it makes the carer feel better or more comfortable. Health care is not (or should not) be provided in the best interests of the care provider but in the best interests of the person in need of that care. Where DNR documentation has been completed the inference is that the interests of the person have been considered and it’s been determined that withholding CPR is in the patient’s best interests.
In some states, there is statutory protection to ensure people that honour DNR type documentation are legally protected (see for example Advance Personal Planning Act 2013 (NT) and Medical Treatment Act 1988 (Vic)). Even where that is not the case the common law still applies to say that people are entitled to refuse consent and that futile treatment may be withheld.
One has to concede that is unlikely a community support worker will be sued or prosecuted for battery for doing CPR but if one is planning to provide care in the client’s best interests and in accordance with the client’s wishes, providing treatment contrary to the terms of a DNR decision is unethical and will expose the client and their family to unnecessary and undesired trauma.
As noted earlier, what is worrying is that a person who is working as a ‘community support worker’ hasn’t been trained by their agency on how to deal with this matter. If support is being provided to a person who is terminally ill or otherwise likely to require CPR, such that decisions have been made to withhold that treatment, the the agency should have procedures to ensure that DNR decisions are recorded and communicated to carers. If necessary discussion should be had with the client, their family and their medical practitioner to ensure that the terms and consequences of the documentation are clear and clearly understood. And staff who are providing care have to be confident to honour their client’s wishes. If that isn’t occurring I would worry about the conduct of the agency that is providing ‘community support’.