Synopsis
Create clinically realistic emergency recommendations that separate cardiopulmonary resuscitation from other treatment decisions and remain lawful, individualised and usable during deterioration.
- A treatment escalation plan describes recommended responses to foreseeable deterioration; DNACPR addresses only CPR after arrest.
- CPR should be considered separately from ward treatment, hospital transfer, high-dependency care, ventilation and other organ support.
- Clinical appropriateness depends on whether CPR could restart circulation and achieve an outcome of overall benefit, not on age alone.
- Discuss recommendations with a patient who has capacity unless they decline information or disclosure would cause serious harm, not merely distress.
- If capacity is absent, identify valid advance refusals and authorised proxies, involve the person as far as possible and consult those close to them.
- No patient or relative can require treatment that the responsible clinician judges clinically inappropriate, but reasons and second-opinion routes should be explained.
- Use uncertainty honestly: a time-limited trial or conditional ceiling may be safer than an absolute prediction when recovery remains plausible.
- Record scope, reasoning, participants, communication needs, review triggers and where the current document can be found.
Key red flags
A DNACPR mark is being used to deny analgesia, oxygen, fracture care, antibiotics or assessment of a reversible emergency.
The recorded recommendation is unsigned, undated, illegible, contradicted by a later plan or does not identify the responsible clinician.
A blanket decision appears based on age, disability, diagnosis, care-home residence or a frailty score rather than individual clinical reasoning.
A patient with capacity disputes the plan or reports that no meaningful explanation of benefits, burdens and alternatives occurred.
Those close to a patient lacking capacity raise a valid advance refusal, legal proxy or evidence of wishes that has not been considered.
Conflict about resuscitation is delaying treatment of pain, breathlessness or another urgent reversible cause of distress.
Investigation priorities
Estimate reversibility and likely CPR outcome.
Management branches
A foreseeable emergency could leave the person unable to express treatment preferences.
- Assess the clinical trajectory and identify specific emergencies, reversible causes and treatment options that are realistically available.
- Ask what outcomes matter, explain likely benefits and burdens in functional terms and establish the person's desired involvement.
- Make separate recommendations for ward or community treatment, transfer, critical care, organ support and CPR where each is relevant.
- Document uncertainty, what active care continues, who was involved and when the plan must be reviewed.