Advance Care Directive, CPR Refusal, and DNR Orders in Tasmania

Two Different Documents, One Decision

There is a persistent confusion in Tasmania between an Advance Care Directive (a legal document you make yourself) and a Do Not Attempt Cardiopulmonary Resuscitation order (a clinical order written by your doctor). They cover related territory — both can result in CPR being withheld — but they are fundamentally different instruments with different legal authority, different authors, and different enforcement mechanisms.

Getting this distinction wrong is not a technicality. It determines whether paramedics start chest compressions when they arrive at your home.

What a DNR (DNACPR) Order Is

A Do Not Attempt Cardiopulmonary Resuscitation order — officially called DNACPR in Tasmanian hospitals — is a medical order written by a treating doctor. It is part of your clinical record, not a legal instrument you create yourself.

In the Tasmanian Health Service, DNACPR status is recorded on the Medical Goals of Care (GOC) Plan (Form S97748). The GOC Plan categorises your care into one of four phases:

• Phase A — Full active treatment, including CPR and Code Blue activation
• Phase B — Active treatment with limits, such as "Not for CPR" but yes to other interventions
• Phase C — Palliative care, comfort-focused, automatically "Not for CPR or intubation"
• Phase D — Comfort care only during the dying process, no active interventions

A patient on Phase B, C, or D effectively has a DNACPR order. But this order is authored and signed by the treating medical practitioner, not by the patient. The doctor makes it based on clinical assessment, the patient's wishes, family consultation, and — critically — any Advance Care Directive the patient has made.

What Your ACD Does About CPR

Your Advance Care Directive is a legal document under Part 5A of the Guardianship and Administration Act 1995. It records your wishes — including whether you want CPR attempted in specific circumstances. When done properly, an ACD carries binding legal force.

But your ACD is not a medical order. A paramedic arriving at a cardiac arrest cannot read your ACD and independently decide not to resuscitate. The ACD informs the clinical team, who then translate your expressed wishes into the appropriate GOC phase and medical orders.

This is why the language in your ACD matters enormously. If your directive says "I do not want to be resuscitated," a treating doctor can translate that into a Phase C or D GOC order — DNACPR — with confidence. If your directive says something vague or contradictory, the doctor has to interpret, and interpretation under emergency time pressure almost always defaults to full active treatment.

The CPR Contradiction That Invalidates Directives

The single most common drafting error in self-made ACDs across Australia is requesting CPR while simultaneously refusing intubation and mechanical ventilation.

Here is why this does not work: CPR is a "package deal." When a person's heart stops, they stop breathing. Chest compressions restore circulation to the brain and organs, but the person is not breathing independently. To deliver oxygen during CPR, the airway must be managed — and that means intubation (a tube inserted into the trachea) and connection to a ventilator.

Requesting CPR but refusing intubation creates a medical impossibility. The treating team cannot perform effective resuscitation without airway management. Faced with this contradiction, clinicians in Tasmania will override the directive under Section 35U of the Guardianship and Administration Act 1995 and default to full active treatment, including intubation — the exact opposite of what most people intend when they write this clause.

If you want to refuse CPR, refuse the whole package: "I refuse cardiopulmonary resuscitation, endotracheal intubation, mechanical ventilation, and defibrillation." If you want CPR attempted but with limits on what happens after, state that clearly — for example, "Attempt CPR for up to 20 minutes; if a stable cardiac rhythm is not restored, cease resuscitation and transition to comfort care."

How to Write CPR Refusal Language That Works

Your ACD refusal language should map directly to the GOC Plan phases used by Tasmanian hospitals. Consider the approach:

For a clear CPR refusal (Phase C/D alignment): "In the event of cardiac or respiratory arrest, I refuse cardiopulmonary resuscitation, intubation, and mechanical ventilation. I direct that my care be oriented toward comfort, pain management, and dignity."

For limited intervention (Phase B alignment): "I consent to active treatment for reversible conditions, including intravenous antibiotics and non-invasive oxygen support. However, I refuse CPR, intubation, and mechanical ventilation. If my condition deteriorates to the point of cardiac arrest, I direct that resuscitation not be attempted."

For full treatment (Phase A alignment): If you want full active treatment including CPR, you do not need to spell this out in your ACD — full treatment is the clinical default in the absence of a directive or GOC order.

What Happens in an Emergency at Home

If you collapse at home and someone calls 000, paramedics are dispatched. Ambulance Tasmania paramedics follow clinical protocols that default to full resuscitation unless they have clear evidence of a valid DNACPR order or ACD.

In practice, paramedics at the scene will:

1. Check for a GOC Plan or clinical letter from the treating hospital (if the patient is receiving palliative care, this is often provided as a wallet card or letter to keep at home)
2. Check for a registered ACD (they may contact the hospital or TASCAT for verification, but this takes time that is not available during a cardiac arrest)
3. If neither is available, begin CPR

This is why storage and accessibility matter as much as the content of your directive. A registered ACD uploaded to My Health Record, with copies distributed to your GP, your Enduring Guardian, and your household, gives paramedics the best chance of identifying your wishes before they begin treatment.

Getting It Right the First Time

The interaction between your legal ACD and clinical GOC orders is the most technically demanding part of advance care planning. Draft it wrong and your directive gets overridden; draft it right and your medical team has a clear, executable instruction set.

The Tasmania Advance Directive & Living Will Kit includes a GOC alignment worksheet that walks you through each clinical phase, helps you draft refusal clauses that map directly to hospital categories, and flags the specific contradictions (like the CPR-intubation trap) that cause directives to fail under real clinical conditions.

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