What are the indications for initiating a Do Not Attempt Resuscitation (DNAR) order in end of life care?

Indications for initiating a Do Not Attempt Resuscitation (DNAR) order in end-of-life care include recognition that a person is entering the last days of life, where resuscitation would not be beneficial or would be inconsistent with the person's wishes and clinical context.

Specifically, DNAR orders should be considered when:

• The person is thought to be in the last days of life, demonstrated by clinical signs such as agitation, Cheyne–Stokes breathing, deterioration in consciousness, mottled skin, noisy respiratory secretions, progressive weight loss, increasing fatigue, loss of appetite, and declining functional status including communication and mobility changes NICE NG31.
• There is a clinical judgement that resuscitation would not achieve the desired outcome or would cause more harm than benefit, considering the person's underlying diagnoses and overall prognosis NICE NG31.
• The person has expressed wishes or advance care plans refusing resuscitation, or lacks capacity and decisions are made in their best interests in line with the Mental Capacity Act 2005 NICE NG108.
• In conditions such as motor neurone disease, decisions about resuscitation and other life-sustaining treatments should be discussed with the person and their family, ensuring that DNAR decisions align with the person’s preferences and clinical status NICE NG42.

Healthcare professionals should involve the person (if possible) and those important to them in discussions about DNAR decisions, ensuring that these decisions are documented and reviewed regularly as the person’s condition changes NICE NG31,NICE NG108,NICE NG142.