DNAR Protocols and the Educational Activities of ACP Promoted Prehospital Care Respecting Patients’ Presumed Intention

Introduction: Conventionally, DNAR (Do Not Attempt Resuscitation) was not permitted in prehospital care by Japanese EMTs. In recent years, the Ministry of Health, Labor and Welfare has been promoting awareness of the Advanced Care Planning (ACP) policy. Accordingly, fire departments, medical associations, care manager liaison conferences, nursing facilities, etc., have been conducting awareness-raising activities on ACP and DNAR, targeting a range of professions, including the general public. In Kobe City, approximately 70 cases/year were deemed suitable for DNAR. Methods: In the Kobe Medical Control (MC) council, a preparatory working group (PWG) for DNAR protocol was established in 2021 with the participation of representatives of care managers, nursing facilities, and women’s associations, as well as medical and legal experts. The PWG decided that 1) presence or absence of ACP should be actively inquired by EMTs at the scene, 2) the patient’s presumed intention is deemed to be applicable when it is confirmed by a family doctor without an official form as Physician Orders for Life-Sustaining Treatment (POLST), and 3) MC physicians are responsible for whole prehospital activities. The new protocol was launched in April 2023. Together, the Kobe City Medical Association has created a patient consent form for ACP instead of POLST and has actively held multiple educational sessions for citizens and health care professionals. Results: In the first year since the program began, there were 78 cases of DNAR application, and 41 cases of CPR being discontinued. Of these, 18 cases were transported to the hospital, 15 cases were handed over to the family, and 8 cases were referred to the family doctor. Conclusion: The introduction of DNAR protocols and the educational activities of ACP across multiple professions have halved the number of patients who received unnecessary CPR against their presumed intention.