Do Not Resuscitate South Australia: DNR, DNACPR, and How Clinical Orders Actually Work
DNR Orders in South Australia Aren't What Most People Think
A do-not-resuscitate order in South Australia isn't something you write into your advance care directive and hand to a hospital. It's a clinical decision made by your treating medical team — and the gap between what families expect and how the system actually works catches people off guard during exactly the wrong moment.
Here's the distinction that matters: your Advance Care Directive (ACD) records your wishes. A Resuscitation Alert — the SA Health clinical document that replaces what people colloquially call a "DNR" — is a medical order that translates those wishes into immediate instructions for clinical staff.
They're two different documents, governed by two different pieces of legislation, serving two different purposes.
The SA Health 7-Step Pathway
South Australia moved away from the informal "DNR" and "NFR" (Not for Resuscitation) scribbles in patient case notes years ago. In their place, SA Health uses a structured clinical tool called the Resuscitation Alert or 7-Step Pathway.
This is a standardised form completed by the senior treating clinician — not the patient or their family. It sits at the front of the patient's physical or electronic case notes and gives specific instructions to nursing and emergency staff about what to do if the patient's condition rapidly deteriorates.
The 7-Step Pathway covers a range of escalation decisions:
- Whether to attempt CPR
- Whether to provide mechanical ventilation
- Whether to transfer the patient to ICU
- Whether to administer IV antibiotics for new infections
- Whether to provide IV fluids and nutrition
- Comfort-care-only parameters
This clinical document operates under the Consent to Medical Treatment and Palliative Care Act 1995, not under the Advance Care Directives Act 2013. Your ACD informs the clinical decision — but the clinician writes the actual order.
How Your ACD Connects to a DNR Decision
When you enter hospital or an aged care facility, the clinical team should check your My Health Record, medical file, and any documents you or your family present. If you have a valid ACD containing clear, specific treatment refusals — for example, "I refuse cardiopulmonary resuscitation if I have an irreversible terminal illness with no prospect of meaningful recovery" — the medical team is legally obligated to follow that binding refusal when making their resuscitation plan.
But here's where complications arise:
Vague instructions get downgraded. If your ACD says something broad like "no heroic measures" or "let nature take its course," clinicians cannot treat that as a binding refusal. Under the Act, it's classified as a non-binding value statement — it guides their thinking but doesn't compel specific actions. In practice, clinicians who face potential civil or criminal liability will err on the side of preserving life when instructions are ambiguous.
The medical futility principle still applies. Doctors are not legally required to provide treatments they assess as medically futile or non-beneficial. If a clinician determines that CPR would cause more harm than benefit — say, for a patient with advanced metastatic cancer and organ failure — they can write a "not for CPR" order even if the patient's ACD or family requests resuscitation. This isn't overriding your wishes; it's the clinician's professional obligation not to provide treatment that would cause suffering without medical benefit.
The 2024 suicide override. Following the Advance Care Directives (Review) Amendment Act 2023 (effective 1 March 2024), clinicians now have explicit statutory authority to administer life-saving treatment in contravention of a binding refusal if they reasonably suspect the patient's life-threatening condition was caused by attempted suicide or self-harm. This addresses the clinical dilemma of someone with a valid DNR-type refusal who is brought in after a deliberate self-harm event.
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What You Should Actually Put in Your ACD
If your goal is to ensure that resuscitation is not attempted in specific clinical scenarios, your ACD needs language precise enough to qualify as a binding provision:
- Name the specific treatments you refuse — CPR, mechanical ventilation, defibrillation, intubation
- Specify the clinical circumstances — "if I have an irreversible condition with no reasonable prospect of recovery," "if I have been diagnosed with a terminal illness and active treatment has been ceased"
- State what you do want — palliative sedation, pain management, comfort care. An SDM cannot refuse comfort care on your behalf, so be clear about the care you want to continue
The more clinically specific your refusals are, the more likely they'll survive the translation from your ACD into the hospital's Resuscitation Alert.
The Family Conversation
One of the most common sources of conflict in hospitals is when a patient's documented wishes differ from what their family wants. Your SDM has the legal authority to consent to or refuse treatment on your behalf — but that authority only activates when you've lost capacity, and only within the scope of your ACD's instructions.
If you've documented a clear, binding refusal of resuscitation and your adult children disagree, the clinical team is required to follow the ACD, not the family's preferences, subject to the statutory exceptions described above. But in practice, bedside disputes create hesitation and delay. Making sure your family understands your documented choices before a crisis hits is essential to avoiding those confrontations.
Our South Australia Advance Directive & Living Will Kit includes a treatment decision worksheet with clinically precise drafting examples and a family conversation planner — so your documented wishes translate cleanly into enforceable clinical orders, and your family knows what to expect.
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