Advance Care Planning and DNACPR
Advance care planning in palliative care encompasses discussion of future care preferences, advance decisions to refuse treatment, and DNACPR/ReSPECT decisions, ensuring care aligns with patient values and wishes.
Key Facts
Advance care planning (ACP) is a voluntary, ongoing process of discussion about future care, values, and preferences DNACPR is a clinical decision that CPR would not be successful or not in the patient's best interests; should involve patient/family discussion ReSPECT process: nationally adopted summary plan for emergency treatment; replaces standalone DNACPR in most areas ADRT (Advance Decision to Refuse Treatment): legally binding under MCA 2005; must be written, signed, and witnessed if refusing life-sustaining treatment Cardiopulmonary resuscitation in advanced cancer: success rate <5% to hospital discharge; much lower in metastatic disease Tracey v Cambridge (2014): landmark case — patients/families must be consulted about DNACPR unless discussion would cause physical or psychological harm ACP should be initiated early in the palliative care trajectory — not left until crisis or last days Preferred priorities of care: document preferred place of care, preferred place of death, treatment escalation limits
Overview
Key Facts
Advance care planning in palliative care ensures that patients receive care that aligns with their wishes and values, even when they can no longer communicate their preferences.
Epidemiology
- CPR survival to discharge in advanced cancer: <5% (often <1%)
- Only ~4% of UK adults have an ADRT
- ReSPECT forms now used in most of England and Wales
- Approximately 70% of people say they prefer to die at home
Aetiology
ACP is important in palliative care because:
- Many patients lose capacity to make decisions as illness progresses
- Without ACP, default care may include unwanted interventions (CPR, ICU admission)
- Discussing ACP improves concordance between patient wishes and actual care received
Pathophysiology
Not a pathological process. ACP is an ethical and legal framework within palliative care.
Clinical Presentation
When to Discuss ACP in Palliative Care
- At diagnosis of life-limiting illness
- When Surprise Question answer is 'No'
- After significant deterioration or hospital admission
- When moving from curative to palliative intent
- At regular palliative care reviews
- At patient's request
Components
- Values, beliefs, what matters most
- Understanding of illness and prognosis
- Treatment preferences (hospital admission, ICU, ventilation)
- DNACPR/ReSPECT
- Preferred place of care and death
- Naming a spokesperson/proxy
- ADRT (specific treatments to refuse)
Red Flags
- DNACPR decision made without patient/family awareness (Tracey v Cambridge ruling)
- ACP documented but not accessible to emergency services
- Patient lacks understanding of their prognosis
- Family requests concealment of diagnosis from patient (cultural sensitivity needed but patient autonomy paramount)
Differential Diagnosis
| Document | Legal Status | Purpose |
|---|---|---|
| Advance statement | Not binding | General wishes and values |
| ADRT | Legally binding | Refuses specific treatment |
| LPA (health) | Legally binding | Proxy decision-maker |
| ReSPECT | Clinical recommendation | Emergency care preferences + CPR decision |
| DNACPR | Clinical decision | CPR decision only |
Diagnosis / Investigation
Bedside
- Capacity assessment (does patient have capacity for ACP discussion?)
- Review existing documents (ADRT, LPA, ReSPECT)
- Explore patient's understanding of illness
- Discuss values, wishes, and preferences
Bloods/Imaging
- Not applicable
Special Tests
- Not applicable
Management
Non-pharmacological
- Initiate discussion: open, honest conversation about future care
- DNACPR decision:
- Clinical decision based on likelihood of CPR success and patient's best interests
- Discuss with patient and/or family (Tracey v Cambridge 2014)
- Document clearly; complete ReSPECT form
- Review regularly (not permanent unless patient has clear ADRT)
- ReSPECT form: complete with patient; includes CPR decision, clinical recommendations, patient preferences
- ADRT: support patient to complete if they wish; ensure valid (written, signed, witnessed for life-sustaining treatment refusal)
- LPA: advise patient to consider health and welfare LPA while they have capacity
- Communicate plan: ensure accessible to all teams (GP, ambulance, hospital, care home)
- EPaCCS/Coordinate My Care: electronic systems for sharing palliative care preferences
- Review regularly: preferences may change over time
Pharmacological
- Not applicable
Surgical/Interventional
- Not applicable
Referral Criteria
- Complex ACP decisions: specialist palliative care
- Capacity concerns: formal capacity assessment
- Legal queries: trust legal department
- Family conflict: mediation, clinical ethics committee
Prognosis
- ACP increases the likelihood of dying in preferred place
- Reduces unwanted hospital admissions and interventions
- Improves family satisfaction and reduces complicated grief
- DNACPR discussions do not increase patient anxiety when handled sensitively
- ReSPECT process is now standard of care in most UK settings
Other Relevant Information
CPR Survival Rates
| Setting | Survival to Discharge |
|---|---|
| In-hospital cardiac arrest (all) | ~20% |
| Out-of-hospital cardiac arrest | ~8-10% |
| Advanced cancer | <5% |
| Metastatic cancer | <1% |
| Frail elderly with multiple comorbidities | <5% |
Tracey v Cambridge (2014)
| Key Point |
|---|
| DNACPR decisions engage Article 8 (right to private life) |
| Patient/family must be consulted unless discussion would cause harm |
| Decision must be clinically justified |
| Must be documented and communicated |
| Failure to consult is a breach of human rights |