Intended for healthcare professionals

Letters “Do not resuscitate” decisions

Full cardiopulmonary resuscitation should not be used for ordinary dying

BMJ 2015; 351 doi: (Published 14 July 2015) Cite this as: BMJ 2015;351:h3769
  1. Gordon Caldwell, consultant physician and clinical tutor1
  1. 1Worthing Hospital, Worthing BN11 2DH, UK
  1. gordon.caldwell{at}

The Analysis article on when and how to discuss “do not resuscitate” decisions with patients evades discussing the difference between ordinary dying and dying from cardiac arrest and attempted full cardiopulmonary resuscitation (CPR).1

In ordinary dying the vital organs fail and the heart is the last vital organ to stop. In cardiac arrest the heart is the first vital organ to stop and full CPR may restore life, whereas in ordinary dying CPR cannot restore life. Cardiac arrest is usually a complication of an acute myocardial infarction.

Most people who die in hospital are clinically frail and die despite “best treatments and doing it all” because all systems fail. Yet unless a do not attempt CPR (DNACPR) order is in place, a cardiac arrest call is put out as the person dies. CPR is a complex, invasive, and traumatic clinical procedure, damaging to the body and to dignity. If we are asked “Did he suffer” after a patient has had a failed CPR, we should answer “Yes, we damaged his body and his dignity.”

Full CPR should be used only for the correct indication—cardiac arrest—and not in the presence of an absolute contraindication, ordinary dying. The General Medical Council guidance says we need to discuss DNACPR only with patients at increased risk of cardiac arrest—those who have had an acute myocardial infarction. However, to protect patients from undignified and brutal dying, we need to complete DNACPR forms. “Goals of care” or the “universal form of treatment options” ( would seem a better approach in clinical frailty than focusing only on DNACPR.2

Doctors should recommend only wise treatments, which are likely to work and that result in more benefit than suffering. Full CPR has no place in the care of clinically frail patients.


Cite this as: BMJ 2015;351:h3769



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