Synopsis
Make, communicate and review individualised decisions about cardiopulmonary resuscitation while preserving the patient’s involvement, distinguishing a clinical recommendation from an advance refusal, and protecting all other appropriate care.
- 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.
Reasoning priorities
Estimate whether CPR could achieve sustained restoration and what burdens are foreseeable.
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.
Worked reasoning
A 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.
- Assess 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.
- Ask permission to discuss future emergencies; explore the patient’s goals and explain CPR separately from antibiotics, oxygen, fluids, symptom relief and hospital transfer.
- In 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.
- Final 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.
- Verification: 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.