Cardiopulmonary resuscitation (CPR) is a life-saving procedure, but when cardiac arrest is expected and CPR is unlikely to succeed or is not in the patient's best interest, discussions about 'Do Not Attempt CPR' (DNACPR) recommendations are crucial. In the UK, there's a shift towards patient and family involvement in these decisions, moving away from paternalistic models. Landmark legal rulings, guidance from the General Medical Council, and statements from professional bodies emphasize the need for shared decision-making. However, the COVID-19 pandemic and Care Quality Commission reports highlighted significant gaps in practice, particularly regarding patient and relative involvement. CPR discussions are clinically, emotionally, and ethically challenging, impacting patients, families, and HCPs. Existing guidelines aim to assist clinicians, yet perceptions of the process are influenced by various societal and cultural factors. This review aimed to explore the experiences of all stakeholders involved in these conversations within the UK context.

The introduction cites several key documents and reports that highlight the shift towards patient-centered care in CPR decision-making in the UK. These include legal rulings emphasizing patient autonomy, guidance from the General Medical Council and professional bodies stressing the importance of involving patients and families, and reports from the Care Quality Commission that identified shortcomings in current practice and the need for improvement. The authors also acknowledge the influence of societal, cultural, and economic factors on perceptions of the CPR decision-making process.

This qualitative systematic review followed the Cochrane Handbook and PRISMA guidelines. A comprehensive search strategy, developed with a health librarian, was used across PubMed, Embase, Emcare, CINAHL, and PsycInfo databases. The search focused on studies published from January 1, 2012, to reflect the current landscape of practice. Inclusion criteria specified adult patients, their families, and HCPs involved in CPR decision-making conversations within the UK. Qualitative studies were included, while quantitative studies, conference proceedings, opinion pieces, reviews, and studies involving children or neonates were excluded. Two reviewers independently screened titles and abstracts, and full texts were assessed for eligibility. The CASP tool was used for critical appraisal, but studies were not excluded based solely on quality assessment. Data extraction used a piloted pro forma, and thematic synthesis was performed for analysis. Reflexivity was employed to manage potential bias from an author's experience as a Resuscitation HCP.

The review included ten studies, nine focusing on HCP experiences and one on patient experiences; none included families. Four key themes emerged: **Theme 1: Initiation of Conversation:** Different perspectives existed on who should initiate (GPs vs. hospital clinicians), with prompts including clinical deterioration, poor prognosis, and transitions to palliative care. Time constraints often influenced when conversations occurred, with hospital settings posing challenges due to time pressures and lack of privacy. **Theme 2: Involvement of Patients and Families:** HCPs sometimes avoided involving patients to prevent distress, while patient views varied. Patients desired family support, but HCPs saw families as potential sources of conflict due to differing perspectives and familial influence on decisions. **Theme 3: Influences on Conversation Content:** The setting (hospital vs. community) significantly influenced the focus of the conversation. HCP attitudes and emotions, particularly anxieties about causing distress, impacted their approach. Uncertainty regarding prognosis also affected the conversation's content and the degree to which patients' wishes were considered. HCPs used both open and closed approaches, with the latter employed when a clear illness trajectory existed. **Theme 4: Conversation Outcomes:** Emotional distress was common for all stakeholders. While some patients found relief in having a plan, others experienced distress and confusion. Disagreements occurred, sometimes leading to second opinions or clinicians conceding to patient wishes despite clinical recommendations. Incomplete conversations also arose due to patient distress or unresolved disagreements.

This review highlights inconsistencies in CPR decision-making conversations within the UK, particularly regarding patient and family involvement. The complexity of these conversations is influenced by a multitude of factors—context, individual perspectives, attitudes, emotions, and ethical considerations. The findings resonate with research on other difficult conversations, such as advance care planning (ACP) and end-of-life (EOL) discussions, where similar challenges arise. The ethical challenges faced by HCPs are central, encompassing the tension between respecting patient autonomy and protecting them from harm. This moral distress can lead to burnout and negative patient outcomes. The review identified a significant gap in research regarding patient and family experiences, emphasizing the need for future studies to address this gap and inform improvements to the quality of these crucial conversations. The authors compared their findings to those of a previous integrative review, noting changes in clinical practice and policy since the earlier research, particularly the 2014 Tracey judgment and the subsequent introduction of ReSPECT.

CPR decision-making conversations in the UK are complex and inconsistent. The ethical challenges faced by HCPs are significant. More research is needed to understand patient and family perspectives. HCPs require training and support; patients and families need education and emotional support.

The main limitation is the scarcity of studies focusing on patient and family experiences. The inclusion of studies of varying quality is another limitation. The focus on UK-based studies might have resulted in the exclusion of relevant international research. The review might also have missed findings from studies where CPR was discussed as part of broader conversations. Despite these limitations, the review provides valuable insights into current practices and challenges.