01Principles and purposeThe professional or clinical skill and the decisions it supports.
CPR is a specific treatment with potentially severe burdens and a probability of benefit that depends on the predicted cause of arrest, underlying health, reversibility and setting. Good decisions start before crisis, include the patient where possible and sit within a broader plan for emergencies. A DNACPR form communicates a recommendation to clinicians; it must not silently become a ceiling on every other intervention.
Professional guidance is UK-wide, but legal authority differs. A valid and applicable advance refusal of CPR can be legally binding under the relevant law; a clinician-authored emergency recommendation is different. The responsible clinician decides whether CPR is clinically appropriate, while a patient with capacity decides whether to accept an offered treatment. Serious disagreement requires senior review, second opinion, mediation, legal advice or court involvement according to urgency and jurisdiction.
Key points
- A DNACPR recommendation concerns CPR after cardiac or respiratory arrest. It does not mean “do not treat”, limit symptom relief, or automatically determine antibiotics, fluids, ventilation, transfer or other emergency interventions.
- Consider CPR individually by balancing likely clinical effectiveness, burdens and the patient’s values. Never apply blanket decisions to age, disability, diagnosis, care-home residence or resource pressure.
- A capacitous patient can make an advance refusal of CPR; clinicians are not required to offer CPR that has no realistic prospect of success, but should explain the decision and offer review or a second opinion.
- Discuss the decision sensitively unless the patient does not want that discussion or it would cause serious physical or psychological harm. Ordinary upset or distress does not meet that exception; document any decision to withhold the discussion.
- If capacity is lacking, check for a valid applicable advance refusal and relevant legal proxy, involve the person as far as possible, and consult those close to them about wishes and values.
- Record the rationale, participants, patient’s wishes, scope, review triggers and communication across settings. Emergency plans such as DNACPR or ReSPECT are clinical recommendations and are not themselves legally binding advance decisions.
02Situations and prioritiesThe context, relevant information and actions that matter most.
When arrest is an expected terminal event and CPR has no realistic prospect of restarting circulation and breathing for a sustained period, the clinical team may conclude it should not be attempted. Explain the reasoning sensitively and continue all other appropriate care.
A person with significant chronic illness may still have a reversible cause of arrest for which CPR could succeed. Avoid diagnosis-based shortcuts; assess the likely circumstances, treatment burden, patient’s goals and uncertainty.
A capacitous patient may refuse CPR prospectively after receiving relevant information. Clarify scope and document the decision using the applicable legal and local process; check whether a formal advance decision is intended.
Transfer, discharge, inaccessible records, ambiguous forms or a plan known only to one team can produce unwanted CPR or inappropriate withholding. Treat interoperability and handover as patient-safety work, not administration.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Clinical likelihood assessment - Why
- Estimate whether CPR could achieve sustained restoration and what burdens are foreseeable.
- Interpretation and limitations
- Use the individual clinical picture, likely arrest mechanism and reversibility. Scores may inform but do not replace judgment, and population survival statistics cannot decide the person’s case.
- 02
Goals and values conversation - Why
- Understand outcomes the patient would regard as acceptable and their information preferences.
- Interpretation and limitations
- Explore survival, function, independence, place of care and burdens rather than asking only “do you want resuscitation?”. Confirm whether the patient wants close others involved.
- 03
Capacity and authority check - Why
- Identify who decides and whether a prior instruction has legal force.
- Interpretation and limitations
- Assess capacity for the CPR decision, search for an advance decision and verify any proxy’s authority and scope. A relative without legal authority informs values but does not simply consent or refuse.
- 04
Plan integrity check - Why
- Confirm scope, signatures, accessibility and consistency with the wider emergency plan.
- Interpretation and limitations
- A clear plan identifies that DNACPR applies only to CPR, records other recommended interventions separately and includes review triggers. Resolve contradictory records promptly.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseFrail patient with a potentially reversible deteriorationA care-home resident with advanced frailty develops pneumonia. The patient has capacity, values comfort but would accept ward treatment, and has no existing emergency plan.+
- 1Assess the acute illness, likelihood that CPR after arrest would achieve an outcome the patient could value, and the burdens of the intervention without using frailty as an automatic exclusion.
- 2Ask permission to discuss future emergencies; explore the patient’s goals and explain CPR separately from antibiotics, oxygen, fluids, symptom relief and hospital transfer.
- 3In this case, senior assessment concludes that CPR offers little likely benefit with substantial burdens. After an explanation of the uncertainty, the patient decides those burdens are unacceptable and declines CPR while continuing to accept treatment on the ward.
- 4Final action: document the patient’s informed CPR decision, the senior assessment and the agreed active treatment and symptom plan, obtaining the responsible clinician’s endorsement and recording when review is needed.
- 5Verification: ensure the patient, care home, GP, ambulance-accessible record and receiving team can access the same plan, and schedule review after recovery or material change.
02Communication approachPatient does not want the discussionA patient with capacity asks not to hear details about a proposed DNACPR recommendation and wants their partner to handle practical information.+
- 1Explore the preference without coercion, confirm the patient understands the topic broadly enough to choose not to receive detail and assess capacity for that choice.
- 2Seek permission to discuss necessary information with the partner and clarify that the clinician retains responsibility for clinical recommendations.
- 3Record the patient’s wish not to discuss details, information given, partner’s involvement and the clinical reasoning for the recommendation.
- 4Keep the offer of discussion open and review if the patient changes their mind, clinical circumstances alter or conflict emerges.
03Conflict approachFamily requests CPR judged clinically inappropriateRelatives insist that CPR must be attempted for a patient lacking capacity, while the responsible team considers CPR unable to provide clinical benefit.+
- 1Listen for the patient’s values and the family’s concerns, correct any belief that DNACPR withdraws other care, and explain the clinical assessment plainly.
- 2Check for valid advance decisions or proxy authority and review the evidence with a senior clinician and the multidisciplinary team.
- 3Offer a second opinion, advocacy, case conference or mediation; continue appropriate treatment and symptom control during resolution.
- 4Seek urgent legal advice or court review for serious unresolved dispute when time permits, documenting decisions and communication throughout.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Review after meaningful clinical improvement or deterioration, change in goals, transfer between settings, new diagnosis, newly available advance decision or concern that the plan no longer reflects the patient.
- During handover, verify both the CPR recommendation and the positive treatment plan; ask the receiving clinician to resolve missing, expired, unsigned or contradictory documentation.
- After an arrest or near miss, examine whether the plan was accessible, correctly interpreted and limited to CPR, then feed system failures into governance review.
- For WPBA reflection, analyse the language used to explain prognosis and uncertainty, evidence that the patient was involved and how disagreement was handled.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Recommendation and refusal differ
A DNACPR or ReSPECT record is a clinician’s recommendation for emergency care and is not itself legally binding. A valid applicable advance decision refusing CPR has a different legal status and must be recognised.
Discussion has exceptions
Discussion of a CPR decision is normally required even when CPR cannot succeed. An exception based on serious physical or psychological harm needs an individual, documented justification. Ordinary distress, clinician discomfort or difficulty explaining the decision is insufficient.
CPR is not a menu item
A patient can decline offered CPR, but cannot require treatment the responsible clinician judges clinically inappropriate. Good practice still requires explanation, exploration of concerns and access to review.
Positive planning prevents misreading
Write what should be done during foreseeable deterioration, not only what should be withheld. A clear escalation and symptom plan reduces the risk that DNACPR is misapplied as therapeutic abandonment.
07Common pitfallsFrequent interpretation and management errors.
- 01
Completing a DNACPR form solely because of age, disability, diagnosis or care setting without an individual clinical and values assessment.
- 02
Asking relatives to “consent to DNACPR” as though they own the decision, rather than clarifying legal authority and learning the patient’s wishes.
- 03
Avoiding a difficult conversation without documenting a specific risk of harm, or telling family while excluding a capacitous patient from their own decision.
- 04
Allowing DNACPR to suppress assessment, ward treatment, symptom control or other emergency interventions that remain appropriate.