Key Facts

DNACPR decisions are among the most sensitive in clinical practice. They reflect the reality that CPR is a medical treatment that may be inappropriate in certain circumstances. The decision must be made transparently, with patient involvement where possible.

Legal and Ethical Framework

• CPR is a medical treatment; there is no absolute right to receive it
• No obligation to provide treatment that will not work (futility)
• Patient's autonomous refusal of CPR must be respected
• Tracey v Cambridge (2014): presumption that patients should be consulted about DNACPR
• Human Rights Act 1998: Article 2 (right to life), Article 8 (right to private life) relevant
• Mental Capacity Act 2005: if patient lacks capacity, decide in best interests

When DNACPR is Appropriate

• CPR is unlikely to be successful (clinical judgement based on condition, comorbidities, frailty)
• Patient has expressed a wish not to be resuscitated (ADRT or verbal wish)
• CPR would not be in the patient's best interests (considering quality of life, burden of treatment)
• Patient is in the terminal phase of illness

ReSPECT Process

• Broader than DNACPR: covers emergency treatment preferences more widely
• Shared decision-making conversation between patient and clinician
• Records: CPR recommendation, ceiling of treatment, treatment goals
• Portable across care settings
• Replaces standalone DNACPR in many organisations

Having the Conversation

• Choose appropriate setting (private, unhurried)
• Assess patient's understanding and wishes
• Explain what CPR involves (chest compressions, ventilation, defibrillation, drugs)
• Discuss likelihood of success honestly
• Explain what a DNACPR decision means (and does NOT mean)
• Emphasise that all other treatment continues
• Involve family with patient's consent (or in best interests if patient lacks capacity)
• Document the discussion and decision

Common Misunderstandings

• DNACPR means 'giving up' — incorrect; all other treatment continues
• DNACPR means no treatment at all — incorrect; only CPR is affected
• Family can demand CPR — incorrect; no obligation to provide futile treatment
• DNACPR is permanent — it should be reviewed regularly
• Only consultants can make DNACPR decisions — any doctor can, though senior input is good practice

Red Flags

• DNACPR placed without discussing with patient or family (unless justified)
• DNACPR influencing other treatment decisions (should not)
• Blanket DNACPR policies for certain groups (age, disability) — unlawful discrimination
• Failure to review DNACPR when circumstances change
• Family overriding patient's own expressed wish

Assessment for DNACPR Decision

• Current diagnosis and prognosis
• Functional status and frailty
• Comorbidities and overall health trajectory
• Likely outcome of CPR (evidence-based estimation)
• Patient's wishes and values
• Previous advance care planning documentation
• Family/carer views (with patient's consent)

CPR Outcome Data

• Overall survival to hospital discharge after in-hospital cardiac arrest: approximately 15-20%
• Survival with shockable rhythm (VF/VT): 25-35%
• Survival with non-shockable rhythm (PEA/asystole): 5-10%
• Metastatic cancer: survival <5%
• Severe frailty (CFS ≥7): survival <5%
• Age >80 with comorbidities: survival approximately 5-10%

Making and Documenting the Decision

• Discuss with patient if they have capacity (Tracey ruling presumption)
• If patient lacks capacity: best interests decision with family/IMCA consultation
• Document: clinical reasoning, discussion with patient/family, patient's wishes, decision, review date
• Complete DNACPR form or ReSPECT form
• Communicate decision to all involved healthcare professionals
• Ensure form is visible and accessible (especially out-of-hours)
• Review decision: at any change in clinical condition, on admission, at transition of care

If Patient Requests CPR Despite Clinical Futility

• Explore understanding and concerns
• Explain honestly and compassionately that CPR would not work
• There is no obligation to provide futile treatment
• Offer second opinion
• Document the conversation

Referral Criteria

• Disputed DNACPR: seek senior clinical opinion, ethics committee
• Patient with capacity refusing DNACPR: respect their autonomous wish (but futile treatment not required)
• Complex cases: palliative care, ethics committee, legal advice if needed

• CPR outcomes are significantly influenced by presenting rhythm, aetiology, comorbidities, and response time
• Appropriate DNACPR decisions prevent distressing futile interventions at end of life
• The ReSPECT process has improved emergency care planning and reduced inappropriate CPR
• CQC inspections assess quality of DNACPR processes
• COVID-19 exposed issues with blanket DNACPR decisions, leading to updated guidance emphasising individual assessment

Tracey v Cambridge University Hospitals (2014)

ReSPECT Form Components