Synopsis
Make individual, evidence-based decisions about cardiopulmonary resuscitation and other escalation, involve the patient or lawful representative, document reasoning and review triggers, and prevent a CPR recommendation from restricting beneficial ordinary treatment.
- Separate the questions: whether CPR could succeed, whether its likely outcome offers overall benefit, whether the patient refuses it, and what other treatments remain appropriate.
- First-line assessment defines the current clinical state, reversible cause, arrest risk, baseline function, prognosis and likely post-CPR outcome before a recommendation is made.
- Discuss CPR when arrest is foreseeable or the patient asks, using plain descriptions of chest compressions, ventilation, low success and possible neurological or functional harm.
- If CPR has a realistic chance of benefit, a capable patient chooses whether to accept or refuse it after supported discussion.
- If CPR will not restart circulation or cannot achieve an overall clinical benefit, the clinician is not obliged to offer it but should explain the recommendation and review route.
- The gold-standard record is individual, clinically reasoned, communicated, dated, signed under local policy and linked to a broader emergency treatment plan.
- ReSPECT or a treatment-escalation plan addresses goals and interventions such as ward treatment, transfer, ventilation or intensive care; it is broader than DNACPR.
- A person lacking capacity is involved as far as possible; follow a valid advance refusal or authorised proxy, otherwise decide overall benefit through a documented best-interests process.
- Review after meaningful change in health, prognosis, treatment options, capacity or wishes; neither indefinite automatic renewal nor routine cancellation is safe.
Key red flags
DNACPR applies only to attempted cardiopulmonary resuscitation after arrest and is never a shorthand instruction to withhold all treatment.
A blanket decision based on age, disability, diagnosis, care-home residence or a group category is discriminatory and clinically unsafe.
A capable patient's informed refusal of CPR must be respected, but a request for CPR does not require clinicians to offer a treatment that cannot work or provide benefit.
When discussion may cause serious harm rather than ordinary distress, any decision not to involve the patient needs specific senior reasoning and documentation.
An advance decision refusing CPR or an attorney's authority must be verified for validity, applicability and scope when the patient lacks capacity.
Material unresolved disagreement needs a second opinion, mediation, ethics or legal review; coercive signatures and rushed forms are unacceptable.
Staff withholding observations, analgesia or reversible-cause treatment because of a CPR form signals an urgent safety and education problem.
Investigation priorities
Define arrest cause and likelihood, reversibility, comorbidity, frailty, baseline function, trajectory and expected outcome after CPR.
Management branches
Cardiorespiratory arrest is foreseeable or a serious deterioration makes emergency planning clinically relevant.
- Review reversibility, arrest likelihood, baseline status and probable outcomes, and identify which other escalation treatments require decisions.
- Assess capacity, ask what the patient understands and values, explain the clinical recommendation and invite questions or an informed refusal.
- Record CPR and broader escalation distinctly, specify care that will continue, share the plan across settings and set clinical triggers for review.