Unwanted cardiopulmonary resuscitation against patients’ “Do Not Attempt Resuscitation” orders in community settings in Japan: A narrative review

We aimed to synthesize existing research to elucidate the underlying factors and causes responsible for the high prevalence of unwanted cardiopulmonary resuscitation (CPR) occurring outside a hospital setting in Japan despite patients' Do Not Attempt Resuscitation (DNAR) orders. We conducted a narrative review by searching PubMed, EMBASE, and Scopus for English literature, and Google Scholar for Japanese literature. The key factors we identified included lack of documentation of resuscitation preferences, variation in the perception of other life-sustaining measures associated with DNAR, non-inclusion of the patient in discussions of goals of care, unlegislated and unstandardized DNAR orders, emergency medical service activation by the family or facility, the Fire Service Act that mandates life-saving measures irrespective of the presence of advance directives, fire department protocols and CPR decision-making, and death pronouncement authorization limited to physicians. This study identified the multifaceted factors and the potential triggers for unwanted CPR despite DNAR orders. These findings underscore the urgent need for comprehensive interventions encompassing educational initiatives, ethical considerations, systemic reforms, and legal adjustments to prevent future unwanted CPRs in Japan. Geriatr Gerontol Int 2024; 24: 1093–1098.