Synopsis
Elicit outcomes that matter, explain realistic options and uncertainty, make lawful shared or best-interests decisions, and convert values into specific treatment, escalation, symptom and contingency plans that remain open to review.
- Goals are outcomes such as comfort, cognition, mobility, longevity, independence, staying home or attending an event—not merely treatment names.
- First-line shared decision-making creates choice awareness, discusses reasonable options including no change, and supports preference after material benefits, harms and uncertainty.
- Ask what the person understands, what matters, what burden is unacceptable and what trade-off they would accept; avoid asking only whether they want everything done.
- Capacity is presumed, supported, decision- and time-specific. An unwise choice does not prove incapacity.
- When capacity is absent, identify any valid advance decision and health-and-welfare attorney, consult prior wishes and those close, and decide best interests least restrictively.
- Advance care planning may record values, preferred place, emergency contacts and treatment preferences; an advance statement informs but does not itself refuse treatment.
- A valid applicable advance decision to refuse treatment is legally binding; refusal of life-sustaining treatment has additional formal requirements.
- DNACPR concerns CPR only. ReSPECT records broader emergency-care recommendations but does not replace clinical judgement, consent or review.
- Offer a time-limited treatment trial when benefit is uncertain and define duration, outcomes, burdens and what happens if the goals are not achieved.
- Communicate decisions across settings, give the person a copy where appropriate and review after clinical, functional or preference change.
Key red flags
Do not interpret DNACPR as no antibiotics, fluids, oxygen, surgery, ward escalation or symptom treatment; each intervention needs its own decision.
A family member described as next of kin cannot consent or refuse automatically; verify health-and-welfare attorney powers or use best interests.
Untreated delirium, pain, hearing loss, language barriers or rushed explanation can impair participation and must be addressed before declaring incapacity.
Coercion, family conflict, fear of care cost or professional pressure can distort stated priorities and requires private supported discussion.
A vague ceiling of care without treatments, triggers, rationale or review point creates dangerous ambiguity during deterioration.
A wish to die may express uncontrolled symptoms, depression, delirium or abuse and needs immediate compassionate risk and symptom assessment.
A relative is asked to decide despite no verified attorney authority and no documented best-interests process.
Staff interpret DNACPR as a general treatment ceiling and risk withholding reversible-illness care.
Investigation priorities
Define the decision and desired outcomes.
Test whether the preferred plan can operate.
Management branches
More than one reasonable care option exists.
- Explain the decision and invite the person's goals, preferred involvement and chosen supporters.
- Discuss reasonable options, no change, absolute benefits, harms, burden and uncertainty in accessible language.
- Reach a preference or allow time, then document rationale, actions, contingency and review while checking understanding.