DNACPR & Advance Decisions

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1. Clinical Overview

Introduction

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions represent one of the most ethically and legally complex areas of modern medical practice. A DNACPR order is a medical decision that cardiopulmonary resuscitation (CPR) should not be performed in the event of cardiac or respiratory arrest. [1]

CPR is a medical treatment that involves chest compressions, ventilation, defibrillation, and advanced life support measures. While often portrayed in media as successful, real-world survival rates vary significantly based on clinical context, with in-hospital cardiac arrest survival to discharge ranging from 15-20% overall, but falling to less than 5% in patients with advanced chronic illness, frailty, or metastatic cancer. [2,3]

Critical Distinctions

DNACPR is NOT:

• A decision to withdraw or withhold other treatments
• A directive to provide substandard care
• Equivalent to "do not treat"
• A decision about other emergency interventions

DNACPR IS:

• A specific decision about ONE intervention (CPR)
• Made in context of overall care planning
• Focused on appropriateness and likely benefit
• Part of broader advance care planning

The terminology "Allow Natural Death" (AND) has been proposed as a more compassionate and accurate description, emphasizing the goal of dignified care rather than focusing on what will not be done. [4]

Historical Context and Legal Evolution

The landscape of DNACPR decision-making has evolved significantly over the past two decades. Traditional medical paternalism, where doctors made unilateral decisions about resuscitation without patient involvement, has been replaced by a legal and ethical framework emphasizing patient autonomy, shared decision-making, and human rights considerations. [5]

The landmark Tracey v Cambridge University Hospitals NHS Foundation Trust (2014) fundamentally changed practice in the UK by establishing that patients have a legal right to be involved in DNACPR decisions under Article 8 of the Human Rights Act (right to respect for private and family life), unless involvement would cause physical or psychological harm. [6]

Key Definitions

DNACPR: Do Not Attempt Cardiopulmonary Resuscitation - a clinical decision that CPR should not be attempted ReSPECT: Recommended Summary Plan for Emergency Care and Treatment - the current UK standard for documenting emergency care preferences ADRT: Advance Decision to Refuse Treatment - a legally binding document (formerly "Living Will") LPA: Lasting Power of Attorney for Health and Welfare - legally appointed decision-maker IMCA: Independent Mental Capacity Advocate - appointed when unbefriended patients lack capacity Medical Futility: Treatment that cannot achieve its physiological objective or the patient's goals of care

The Three Pillars of DNACPR Decision-Making

All DNACPR decisions rest on one or more of three foundations:

1. Clinical Futility CPR will not restart the heart or will not lead to survival beyond the immediate resuscitation. The senior clinician makes this determination based on evidence and experience. Patients cannot demand futile treatments, but must be involved in discussions. [7]

2. Patient Choice (Autonomy) A patient with capacity refuses CPR after understanding the information. This decision must be respected regardless of the clinician's view of the wisdom of that choice. Capacity-specific and time-specific. [8]

3. Best Interests (Incapacity) When a patient lacks capacity, CPR may be considered not in their best interests because the burdens (suffering, loss of dignity, prolonged dying) outweigh potential benefits. This requires structured assessment involving those close to the patient. [9]

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2. Legal and Ethical Framework

The Mental Capacity Act 2005 (England & Wales)

The Mental Capacity Act 2005 provides the statutory framework for decision-making for adults who lack capacity. Scotland has the Adults with Incapacity (Scotland) Act 2000, and Northern Ireland has separate but similar provisions. [10]

The Five Statutory Principles

Principle 1: Presumption of Capacity Every adult must be assumed to have capacity to make their own decisions unless it is established that they lack capacity. Age, appearance, condition, or behaviour should not lead to unjustified assumptions.

Principle 2: Support to Make Decisions A person must be given all practicable help to make their own decision before being treated as unable to do so. This includes:

• Using simple language
• Visual aids and diagrams
• Involving speech and language therapy
• Choosing optimal time of day (when person is most alert)
• Involving family members who can help explain

Principle 3: Right to Make Unwise Decisions A person is not to be treated as unable to make a decision merely because they make an unwise decision. Autonomy includes the right to make decisions others disagree with, provided the person has capacity.

Principle 4: Best Interests Any act done or decision made under the MCA for someone who lacks capacity must be in their best interests.

Principle 5: Least Restrictive Option Before making a decision, consideration must be given to whether the purpose can be achieved in a way less restrictive of the person's rights and freedom of action.

The Two-Stage Test of Capacity

Stage 1: Diagnostic Test Is there an impairment of, or disturbance in the functioning of, the person's mind or brain? This could be:

• Permanent (dementia, severe learning disability, brain injury)
• Temporary (delirium, acute psychosis, medication effects)
• Fluctuating (delirium superimposed on dementia)

If yes, proceed to Stage 2.

Stage 2: Functional Test - The Four-Part Assessment

The person must be able to:

1. Understand the information relevant to the decision

• What is CPR? (Chest compressions, electric shocks, breathing tube)
• Why are we discussing it? (Your heart/breathing might stop)
• What happens if CPR is attempted? (Possible outcomes: success, failure, complications)
• What happens if CPR is not attempted? (Natural death)

2. Retain that information Long enough to make the decision (this might be only minutes, not days). Short-term memory impairment does not automatically mean incapacity if the person can retain information long enough to weigh it up.

3. Weigh up the information Consider the pros and cons:

• Potential benefits: Survival, more time with family
• Potential burdens: Rib fractures, hypoxic brain injury, ICU admission, prolonged dying The person must be able to engage in this weighing process, even if they come to a conclusion others disagree with.

4. Communicate the decision By any means - speech, sign language, eye blinks, squeeze of hand. Communication aids must be provided.

Key Legal Points on Capacity Assessment

• Decision-specific: A person may have capacity for some decisions (what to eat) but not others (complex medical treatment)
• Time-specific: Capacity can fluctuate (delirium, medication effects)
• Capacity is assumed until proven otherwise: The burden of proof lies with those asserting incapacity
• Document the assessment: Record which parts of the test were failed and the evidence

Best Interests Decision-Making (Section 4 MCA)

When a person lacks capacity, decisions must be made in their best interests. This is not what the doctor thinks is medically best, nor what the family wants, but a structured consideration of multiple factors:

1. Consider all relevant circumstances

• Clinical condition and prognosis
• Alternative treatments available
• Likelihood of recovery
• Patient's known wishes and values

2. Consider if/when the person will regain capacity If capacity might be regained (e.g., treating delirium), can the decision wait?

3. Encourage participation Even if the person lacks capacity to make the decision, involve them as much as possible in the process.

4. Consider the person's past and present wishes, feelings, beliefs, and values

• What did they say when they had capacity?
• What are their cultural, religious, spiritual beliefs?
• What brought them meaning and quality of life?
• How did they approach previous illness?

5. Consult others

• Anyone named by the person to be consulted
• Those engaged in caring (family, friends)
• Lasting Power of Attorney (if appointed)
• Deputies appointed by the Court of Protection
• IMCA (if applicable and no one else available)

6. Not based on age, appearance, condition, or behaviour

7. Consider whether life-sustaining treatment is in best interests Must not be motivated by a desire to bring about death. However, continuation of life is not automatically best interests if quality of life would be unacceptable to the patient.

Landmark Case Law

Tracey v Cambridge University Hospitals NHS Foundation Trust [2014] EWCA Civ 822

Facts: Janet Tracey was admitted with lung cancer and cervical fracture. A DNACPR was placed on her record without her knowledge. She died four days later. Her family discovered the DNACPR only after her death and brought judicial review proceedings.

Legal Issues:

1. Did the clinicians have a common law duty to consult?
2. Was there a breach of Article 8 rights (private and family life)?

Judgment: The Court of Appeal held that:

• There is a presumption in favour of patient involvement in DNACPR decisions
• Article 8 is engaged because DNACPR affects the way the patient is treated in the last moments of life
• Clinicians must consult unless they consider involvement would cause physical or psychological harm
• "Distress" is not the same as "harm"
• difficult conversations that cause upset are still required
• Burden of proof that discussion would cause harm lies with clinicians
• Harm must be more than transient upset

Impact on Practice: This case fundamentally changed UK practice, making patient involvement mandatory unless exceptional circumstances exist.

Winspear v City Hospitals Sunderland NHS Foundation Trust [2015] EWHC 3250

Facts: David Winspear lacked capacity. At 03:00, doctors made a DNACPR decision without consulting his mother (who held LPA for health and welfare) because it was "too late to call."

Judgment:

• Convenience is never a justification for failing to consult
• Discussion should occur at the "earliest practicable opportunity"
• Out-of-hours decisions should be reviewed and discussion held as soon as possible
• LPAs must be consulted in Best Interests decisions

Impact: Reinforced that procedural compliance with MCA cannot be sacrificed for convenience.

Re Burke [2005] EWCA Civ 1003

Facts: Mr Burke had cerebellar ataxia and wanted assurance he would receive artificial nutrition and hydration (ANH) when he lost capacity.

Judgment:

• Competent patients can refuse treatment (including life-sustaining treatment)
• Competent patients cannot demand treatment the clinician considers not clinically indicated
• Where treatment is futile or burdensome, it need not be provided even if demanded
• However, clinicians must carefully consider best interests and cannot unilaterally withdraw life-sustaining treatment

Relevance to DNACPR: Patients cannot demand CPR if it is futile, but they retain the right to be involved in the discussion.

Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67

Facts: Mr James was in a minimally conscious state following complications of surgery. Hospital sought declaration that CPR was not in his best interests. Family wanted all treatment including CPR.

Judgment (Supreme Court):

• Best interests test applies to all decisions
• The test is not "Is life worth living?" but "Is the proposed treatment in the patient's best interests?"
• Strong presumption in favour of preservation of life
• But this is not absolute - futile treatment causing suffering is not in best interests
• "Futility" means treatment that cannot achieve its purpose

Impact: Clarified that medical futility can override family wishes, but requires robust justification.

Human Rights Act 1998

Article 2: Right to Life

• Imposes positive obligation on NHS to provide life-saving treatment
• But does not require provision of futile treatment
• Protects against unlawful ending of life

Article 3: Prohibition of Torture and Inhuman or Degrading Treatment

• Subjecting a dying patient to violent, futile CPR could potentially breach Article 3
• Used in cases where treatment causes suffering without benefit

Article 8: Right to Respect for Private and Family Life

• Engaged in DNACPR decisions (Tracey)
• Requires patient involvement in decisions about end of life
• Balances against Article 2

Article 14: Prohibition of Discrimination

• DNACPR decisions must not discriminate on grounds of age, disability, race, religion
• "Blanket" policies applied to categories (e.g., care home residents, learning disability) are unlawful

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3. Clinical Indications for DNACPR

Evidence-Based Assessment of CPR Outcomes

Understanding the likely success of CPR is fundamental to making clinically appropriate DNACPR decisions. Success must be defined not merely as return of spontaneous circulation (ROSC), but as survival to hospital discharge with acceptable quality of life. [2]

Overall Survival Rates

In-Hospital Cardiac Arrest (IHCA):

• Immediate ROSC: 30-40%
• Survival to 24 hours: 20-25%
• Survival to hospital discharge: 15-20%
• Survival to one year: 10-15% [2,3]

Out-of-Hospital Cardiac Arrest (OHCA):

• Bystander CPR initiated: 10-12% survival
• No bystander CPR: 3-5% survival
• Overall survival to discharge: 7-8% [11]

Factors Associated with Poor Outcomes

Patient Factors:

• Age > 80 years: 5-8% survival to discharge [12]
• Metastatic cancer: less than 1% survival to discharge [13]
• Advanced dementia: less than 2% survival to discharge [14]
• Multi-organ failure: less than 5% survival
• Severe chronic lung disease (home oxygen): 5-7%
• Advanced heart failure (NYHA IV): 3-5%
• Severe frailty (Clinical Frailty Scale 7-9): less than 3%

Arrest Factors:

• Unwitnessed arrest: less than 5% survival
• Non-shockable rhythm (PEA/asystole): 2-5% survival
• Prolonged arrest (> 20 minutes): less than 1% survival with good neurological outcome

Complications of CPR:

• Rib fractures: 30-90% (age and osteoporosis dependent) [15]
• Sternal fracture: 20-30%
• Pneumothorax: 10-15%
• Visceral injury (liver, spleen): 5-10%
• Hypoxic brain injury: 30-50% of survivors
• Aspiration pneumonia: 20-30%

Clinical Scenarios Where DNACPR Should Be Considered

1. Medical Futility

CPR is considered futile when it cannot achieve its physiological objective (restart the heart) or cannot achieve the patient's goals of care. [7]

Examples:

• Terminal phase of illness (hours to days prognosis)
• Multi-organ failure unresponsive to treatment
• Metastatic cancer with deterioration
• End-stage organ failure (heart, lung, liver, kidney)
• Advanced frailty with acute deterioration

Clinical Approach: This is a medical decision, but requires discussion with patient/family to explain the rationale. The decision-maker is the senior clinician, but Article 8 rights require involvement of patient.

2. Quality of Life Considerations

CPR might restart the heart, but the patient's quality of life after CPR would be unacceptable to them, or survival would be brief before re-arrest. [8]

Examples:

• Advanced dementia - patient would not understand ICU environment, attempts at weaning would cause distress
• Severe neurological disability - further hypoxic insult would worsen function
• Patient's stated values prioritize dignity and quality over prolongation

Clinical Approach: This is a shared decision requiring exploration of patient values, beliefs, and preferences. Medical opinion informs prognosis, but patient/family perspective determines what "acceptable outcome" means.

3. Patient Refusal

A patient with capacity has the absolute right to refuse CPR for any reason or no reason. [8]

Clinical Approach:

• Ensure patient understands what CPR involves
• Ensure capacity is present
• Document the discussion
• Respect the decision even if you disagree

Conditions Where DNACPR is Often Appropriate

Oncology:

• Metastatic solid tumours progressing despite treatment
• Haematological malignancies relapsed after stem cell transplant
• Cancer-related complications (SVC obstruction, carcinomatosis)

Cardiology:

• End-stage heart failure despite optimal therapy
• Cardiogenic shock unresponsive to inotropes/mechanical support
• Multi-vessel coronary disease not amenable to revascularization with poor LV function

Respiratory:

• End-stage COPD (FEV1 less than 30%, home oxygen, frequent admissions)
• Pulmonary fibrosis with severe impairment
• Motor neurone disease with respiratory failure

Neurology:

• Advanced dementia (FAST stage 7)
• Progressive neurodegenerative conditions (MND, MSA, PSP)
• Severe stroke with multi-organ complications

Geriatrics:

• Severe frailty (CFS 8-9) with acute illness
• Multiple co-morbidities with cumulative burden
• Recurrent aspiration in stroke/dementia patients

Intensive Care:

• Multi-organ failure not responding to organ support
• Prolonged ICU stay with no improvement trajectory
• Complications rendering further escalation non-beneficial

Conditions Where DNACPR May Be Inappropriate Without Discussion

• Acute reversible conditions (diabetic ketoacidosis, sepsis with no co-morbidities)
• Single organ failure amenable to treatment
• Young patients with acute illness
• Patients who have expressed desire for full escalation

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4. The ReSPECT Process

Background and Development

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was developed by the Resuscitation Council UK in collaboration with multiple stakeholders to address limitations of traditional DNACPR forms. [16]

Problems with Traditional DNACPR Forms:

• Binary (CPR yes/no) without context of broader care
• Often interpreted as "do not treat"
• Limited information transfer across care settings
• No patient priorities documented
• Focus on what NOT to do rather than positive care planning

ReSPECT Advantages:

• Holistic emergency care planning
• Patient priorities documented prominently
• Clinical recommendations in context of overall care
• Portable across care settings
• Regular review prompts

ReSPECT Form Structure

The ReSPECT form is a standardized document, but implementation varies by region. The core structure includes:

Section 1: Personal Details

• Name, date of birth, NHS number
• Address and usual residence
• Care home or own home
• Contact details for next of kin/LPA

Section 2: Summary of Clinical Condition

Brief summary of the clinical situation prompting this conversation:

Good Example: "85-year-old with severe COPD (FEV1 25%, home oxygen 16h/day), previous ICU admission requiring intubation (2023), poor functional status (housebound), recent admission with infective exacerbation requiring NIV."

Poor Example: "Elderly COPD patient."

The clinical summary provides context for emergency responders and receiving clinicians.

Section 3: Personal Preferences (What Matters to Me)

This is the most important section - the patient's voice.

Prompting Questions:

• What matters most to you right now?
• What are you hoping for?
• What are you worried about?
• Where would you like to be cared for?
• Are there specific things you want to avoid?

Good Examples:

• "I want to be at home with my dog. I've had enough of hospitals. I'm not afraid of dying but I am afraid of pain."
• "I want to live long enough to see my grandson graduate in July. After that, I don't want aggressive treatment."
• "My faith is very important. I want a priest available if I am deteriorating."
• "I don't want to be confused or sedated - I prefer being alert even if that means more discomfort."

Poor Examples:

• "Comfortable"
• "Good quality of life"
• "No suffering"

(Too vague - everyone wants these things; need specificity)

Section 4: Clinical Recommendations for Emergency Care

This section uses a scale rather than binary choices:

Life-Sustaining Treatment Focus ┌─────────────────────────────────────┐ │ A: Prioritise extending life │ │ - Full escalation including ICU │ │ - Intubation if required │ │ - All active treatments │ ├─────────────────────────────────────┤ │ B: Select treatments that may extend │ │ life (with limitations) │ │ - Ward-based care only │ │ - IV antibiotics and fluids │ │ - Non-invasive ventilation │ │ - NOT for ICU/intubation │ ├─────────────────────────────────────┤ │ C: Prioritise comfort │ │ - Symptom control only │ │ - Oral medications │ │ - Subcutaneous medications │ │ - No hospital transfer │ └─────────────────────────────────────┘

Specific Interventions - Document what IS appropriate:

• Antibiotics (oral, IV, both, neither)?
• Fluids (oral, IV, subcutaneous)?
• Hospital admission?
• Non-invasive ventilation?
• Blood transfusion?

Section 5: Cardiopulmonary Resuscitation Recommendation

Separate box specifically for CPR:

CPR Recommended (Red background) ✓ If cardiac arrest occurs, attempt CPR

CPR NOT Recommended (Blue background) ✓ If cardiac arrest occurs, do not attempt CPR Reason: □ Futile □ Patient preference □ Not in best interests

Critical Point: The CPR decision is embedded within broader care planning, not isolated.

Section 6: Involvement in Decision-Making

Capacity Declaration:

• Patient has capacity for this discussion: Yes/No
• If No, specify reason (unconscious, delirium, dementia, etc.)

Who Was Involved:

• Patient (if capacity present)
• Lasting Power of Attorney
• Family members/friends (names and relationship)
• IMCA
• Other (specify)

Patient Agreement:

• Patient agrees with plan
• Patient does not agree (document objection)
• Patient lacks capacity (best interests decision)

Section 7: Clinician Signature and Review

Senior Clinician Signature: Must be signed by senior decision-maker:

• Consultant
• GP
• Specialty Registrar (StR) with consultant oversight

Review Date: Specify when the plan should be reviewed:

• Specific date (e.g., "3 months" for stable chronic condition)
• Trigger (e.g., "if condition changes" for fluctuating illness)
• "On discharge from hospital"

Avoid: "Indefinite"

• even permanent conditions should have "annual review" or "if condition changes."

Section 8: Emergency Contacts

Contact details for:

• GP surgery
• Community palliative care team
• District nursing team
• Care home (if applicable)
• Family contact (24-hour number)

Implementation and Portability

The ReSPECT form must travel with the patient:

• Home to ambulance (visible location - fridge, green folder)
• Ambulance to Emergency Department
• Hospital to care home
• Hospital to hospice

Digital Integration: Many regions now have electronic ReSPECT accessible via:

• GP systems (EMIS, SystmOne)
• Ambulance service tablets
• Hospital EPR systems

Common Errors in ReSPECT Completion

1. Vague Personal Preferences ❌ "Wants to be comfortable" ✓ "Wants to remain at nursing home. Willing to have oral antibiotics but not hospital transfer. Granddaughter's wedding in June is priority."

2. Inconsistent Recommendations ❌ Section 4: "Prioritise comfort" Section 5: "CPR recommended" (Contradictory - if prioritizing comfort, CPR inappropriate)

3. Inadequate Clinical Summary ❌ "Cancer" ✓ "Metastatic pancreatic cancer, diagnosis 06/2025, declined chemotherapy, performance status 3, prognosis weeks-months"

4. Missing Capacity Assessment Failing to document WHY patient lacks capacity

5. No Review Date Using "indefinite" instead of specific date/trigger

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5. Advance Decisions to Refuse Treatment (ADRT)

Legal Framework

An Advance Decision to Refuse Treatment (ADRT), formerly called a "Living Will," is a decision made by a person aged 18 or over, with capacity, to refuse specified medical treatment in the future if they lose capacity. [17]

Legal Basis: Mental Capacity Act 2005, Sections 24-26

Key Principle: An ADRT has the same legal force as a contemporaneous refusal made by a person with capacity. Healthcare professionals who provide treatment in the face of a valid and applicable ADRT may be liable for battery (assault).

Requirements for Validity

For Non-Life-Sustaining Treatment: An ADRT can be written or verbal and must specify:

• Which treatment is refused
• In which circumstances

For Life-Sustaining Treatment: Additional requirements apply:

1. Must be in writing
2. Must be signed by the person making it
3. Must be witnessed (signature witnessed by another person)
4. Must include a specific statement that the decision applies even if life is at risk

Example Statement: "I [name] refuse [treatment] even if my life is at risk as a result."

Assessing Validity

Before relying on an ADRT, clinicians must assess if it is valid and applicable.

Validity Checklist:

• Was it made by a person aged ≥18?
• Did they have capacity when they made it?
• Were they free from coercion?
• Have they withdrawn it since? (Verbally or in writing)
• Have they done anything inconsistent with it? (e.g., ADRT refuses antibiotics, but patient recently accepted antibiotics)
• Have they appointed an LPA since, giving them authority to make this decision? (LPA made AFTER ADRT overrides ADRT)

Applicability Checklist:

• Does the current situation match the circumstances specified?
• Are there reasonable grounds to believe circumstances exist that the person did not anticipate and would have affected their decision?

Example of Non-Applicable ADRT: ADRT states: "If I have dementia and develop pneumonia, I refuse antibiotics." Current situation: Patient has dementia and has fractured neck of femur. → ADRT does not apply to current situation (fracture, not pneumonia)

What Can and Cannot Be Refused in an ADRT

Can Be Refused:

• CPR
• Mechanical ventilation
• Antibiotics
• Blood transfusion
• Artificial nutrition and hydration
• Chemotherapy
• Surgery
• Dialysis
• Any specific medical treatment

Cannot Be Refused:

• Basic nursing care (warmth, hygiene, pain relief)
• Symptom control for comfort
• Offer of oral food and fluids (though can refuse if offered)

Cannot Demand:

• Assisted dying
• Specific treatments (ADRTs are refusals, not requests)
• Illegal acts

Interaction with Lasting Power of Attorney (LPA)

LPA for Health and Welfare: A legal document appointing someone to make health decisions if capacity is lost.

If Both ADRT and LPA Exist:

• Which was created most recently?
  • ADRT made BEFORE LPA → LPA can override (if LPA given authority over that decision)
  • ADRT made AFTER LPA → ADRT takes precedence for the specific refusal
• Best practice: Review and reconcile both documents

Avoiding Conflict: When making an LPA, explicitly state: "My attorney may make decisions about life-sustaining treatment" (this gives them authority to override previous ADRTs)

Clinical Management When ADRT Found

Scenario: Paramedics called to cardiac arrest, family produces ADRT refusing CPR.

Action Steps:

1. Assess validity: Written, signed, witnessed, statement re: life risk?
2. Assess applicability: Does it apply to this situation (cardiac arrest)?
3. Check for withdrawal: Has patient verbally withdrawn it? Anything inconsistent?
4. If valid and applicable: Do not provide the refused treatment (stop CPR)
5. If doubt about validity/applicability: Treat to preserve life and seek urgent legal advice
6. Document: Record ADRT seen, assessment of validity/applicability, action taken

Protection for Clinicians:

• Acting in accordance with valid and applicable ADRT: Legally protected
• Treating in face of doubt about validity: Legally protected if acting in good faith to preserve life
• Treating despite valid applicable ADRT: Potentially liable for battery

Practical Issues

1. Finding the ADRT

• ADRTs are often at home when patient is in hospital
• National registries exist but not universally used
• "Green Folder" schemes in community (visible location)

2. Ambiguous Language Example: "I do not want to be kept alive on machines."

• Does this mean ventilator? Dialysis? Syringe drivers?
• Ambiguity leads to non-applicability (treat if in doubt)

3. Changed Circumstances Example: ADRT written 10 years ago refusing intubation "if I have dementia"

• Medical advances since then (less invasive ventilation)
• Patient's dementia is mild, not severe
• May argue circumstances not as anticipated

4. Pregnancy ADRT is not applicable during pregnancy (unless otherwise specified), to protect fetal rights.

Relationship to DNACPR

• ADRT can refuse CPR (if valid and applicable, must be followed)
• DNACPR is a clinical decision (can be made even if patient has capacity and agrees)
• ADRT refusing CPR should prompt DNACPR documentation for emergency responders

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6. Communication Skills and Difficult Conversations

The Challenge

Discussing DNACPR is consistently rated by clinicians as one of the most difficult conversations in medicine. Common barriers include: [18]

• Fear of destroying hope
• Concern about causing distress
• Uncertainty about prognosis
• Cultural and religious sensitivities
• Time pressure
• Personal discomfort with death

However, evidence shows that patients with serious illness want these discussions and that honest, empathetic communication improves patient satisfaction, reduces anxiety, and ensures care aligns with values. [19]

SPIKES Framework for Breaking Serious News

Developed for oncology but applicable to DNACPR discussions: [20]

S - Setting

Physical Environment:

• Private space (side room, quiet room, not bedside bay with curtain)
• Sit down at eye level (standing conveys hurry/authority imbalance)
• Minimize interruptions (bleep to colleague, phone on silent)
• Tissues available

Who Should Be Present:

• Ask patient: "Is there anyone you'd like to be here for this conversation?"
• Respect refusal of family presence
• If patient lacks capacity, involve LPA/family

Your Preparation:

• Review clinical facts (prognosis, co-morbidities)
• Clarify your goal (seek consent for DNACPR? Inform of decision?)
• Emotional preparation (this is hard for you too)

P - Perception

Assess what the patient already knows and understands:

• "What's your understanding of your illness at the moment?"
• "What have the doctors told you about your heart condition?"
• "What are you expecting might happen?"

Why This Matters:

• Reveals knowledge gaps
• Shows if patient has insight into severity
• Identifies unrealistic expectations that need addressing

Responses Reveal Much:

• "I know I'm very sick" → Patient has insight
• "I'm going to get better and go home" → Expectations not aligned with reality

I - Invitation

Check if the patient wants to have this discussion now:

• "Is it okay if we talk about planning for emergencies?"
• "I'd like to discuss what we would do if you became more unwell - is now a good time?"

Respect Refusal: Some patients do not want to discuss death. This can be culturally appropriate or a psychological defense mechanism.

• Document that opportunity offered
• Revisit at later time
• Can still proceed if clinical futility (consult family if patient declines involvement)

K - Knowledge (Delivering Information)

Warning Shot: "I'm afraid I have some difficult information to share."

Use Clear, Simple Language: ❌ "Your cardiac output is severely reduced and your multi-organ dysfunction syndrome suggests a poor short-term prognosis." ✓ "Your heart is very weak and your kidneys and liver are struggling. I'm worried that your body is reaching the point where it can't recover."

The Futility Explanation (if CPR futile): ❌ "Do you want us to resuscitate you?" ❌ "If your heart stops, shall we jump on your chest?"

✓ "I need to talk to you about a treatment called CPR - cardiopulmonary resuscitation. This is where if your heart stops, we would do very vigorous chest compressions, give electric shocks, and put a breathing tube in. It's what you might see on TV medical dramas.

The reason I'm bringing this up is that I'm worried that your [condition] is now so advanced that if your heart stopped, it would be because your body has reached its limit. CPR would involve breaking ribs and it would not restart your heart in a lasting way. I don't believe it would work, and I think it would cause suffering without benefit.

What I'm recommending is that if your heart were to stop naturally, we would allow you to die peacefully. We would absolutely continue all your other treatments - antibiotics, fluids, oxygen, pain relief - but we wouldn't try to restart your heart artificially."

The Patient Choice Explanation (if patient has capacity): "Some people in your situation choose to have CPR attempted if their heart stops. Others feel that they have lived a good life and prefer to allow nature to take its course peacefully. There's no right or wrong answer - it's about what matters to you. Can I ask what you think about this?"

E - Empathy

Respond to emotion with empathy:

Identify the emotion:

• Silence, tears → Sadness
• "This is ridiculous!" → Anger
• "But I'm not ready" → Fear
• Looking down, withdrawn → Shame/isolation

Name the emotion (validates it): "I can see this is very distressing." "I can hear you're angry."

Respect the emotion (don't try to fix it): Silence is powerful - sit with discomfort "I wish the situation were different." "I'm so sorry."

Wrong Responses (minimize emotion): ❌ "Don't cry, it will be okay." ❌ "You need to be strong for your family." ❌ "At least you've had a good life."

S - Strategy and Summary

Agree on Next Steps:

• "So we're going to put a DNACPR form in your notes. This means if your heart stops, we will let you die peacefully."
• "All your other treatments continue - antibiotics, oxygen, fluids."
• "If you become breathless, we'll give you morphine to help."
• "We'll make sure you're comfortable and your family can be with you."

Check Understanding: "Can I just check - what's your understanding of what we've discussed?"

Open Door: "If you have more questions later, please ask the nurses to call me."

Handling Specific Difficult Scenarios

Scenario 1: "Do Everything" / "Don't Give Up on Me"

What They Usually Mean:

• Don't abandon me
• Don't let me suffer
• Treat me with dignity
• I'm not ready to die

What They DON'T Usually Mean:

• Provide futile treatments
• Cause me harm in the name of prolonging life

Response: "I hear that you want us to do everything we can, and I promise you we will. We will treat your infection with antibiotics, give you oxygen, keep you comfortable. What I'm saying is that ONE specific treatment - CPR - doesn't work in your situation and would cause harm. We're not giving up on you; we're making sure we're doing the right things, not everything."

Scenario 2: Religious Objections ("Only God Decides")

Acknowledge the Belief: "I respect your faith, and I understand that life is sacred in your belief system."

Reframe: "My role as a doctor is not to end life. I'm talking about not starting a treatment that won't work. If your heart stops naturally, that is the outcome of your illness, not a choice I'm making. I cannot fight against God's will with a treatment that won't work."

Offer to Involve Chaplaincy: "Would it be helpful to speak with the hospital chaplain or your own faith leader about this?"

Scenario 3: Family Disagreement

Patient Has Capacity: "I understand you disagree with your father's decision, but he has the legal right to make this choice for himself. What we can do is make sure he's fully understood the information."

Patient Lacks Capacity - Family Conflict: "I'm hearing different views about what your mother would have wanted. My job is to make a decision in her best interests based on all the information. Can each of you tell me what you know about what she valued and feared?"

Family Demands Futile Treatment: "I understand you want us to try CPR. However, my professional opinion is that it will not restart her heart, and it will cause her body to be subjected to injury at the moment of her death. I cannot provide a treatment that I believe will cause harm without benefit. What I can do is ensure she is comfortable, pain-free, and that you can be with her."

Scenario 4: "Why Are You Giving Up?"

Explore the Question: "Can you tell me more about what you mean by giving up?"

Reframe as Redirecting, Not Giving Up: "We're not giving up. We're changing our focus from trying to cure your disease to making sure you're comfortable and making the most of the time you have. That's still very active care - it's just different care."

Scenario 5: "My Uncle Had CPR and Survived"

Acknowledge: "I'm glad to hear that worked for your uncle."

Differentiate: "Every situation is different. CPR can work in some situations - for example, if someone has a heart attack in hospital and we can treat it quickly. But in [patient's] situation, the heart is stopping because the body is shutting down from [illness]. That's a very different situation."

Communication Across Cultures

Different cultures have different approaches to discussing death and decision-making: [21]

Collectivist Cultures (family-centered decision making):

• Many Asian, Middle Eastern, Southern European cultures
• Family may wish to protect patient from bad news
• Decision-making is family decision, not individual
• Respect this, but explain UK legal framework (patient autonomy if capacity present)

Approach: "I understand in your culture the family makes decisions together. In the UK, the law says I must speak with [patient] because he has the right to know and decide. However, would [patient] like you present for the discussion?"

Cultures with Strong Religious Views on Death:

• Orthodox Judaism: Saving life paramount, may object to DNACPR
• Islam: Life is sacred, but prolonging suffering not required
• Catholicism: Proportionate treatment, not obliged to pursue "extraordinary means"

Approach: "Does your faith have specific teachings about medical treatment at the end of life?" Offer involvement of faith leader/chaplain.

Documentation of the Discussion

Essential Elements:

1. Date, time, location
2. Who was present
3. What information was shared (prognosis, CPR success likelihood)
4. Patient/family response
5. Questions asked and answered
6. Decision made and rationale
7. Plan for review

Example: "14:30, Side Room 2. Discussion with Mrs X and her daughter re: DNACPR. Explained that advanced heart failure and multiple admissions indicate deteriorating trajectory. Discussed CPR involves chest compressions and likely success less than 5% given her condition. Mrs X stated 'I've had a good life and don't want to be thumped about at the end.' Daughter initially upset but after further discussion understood mother's wishes. Mrs X has capacity (understands, retains, weighs, communicates). DNACPR form completed reflecting patient choice. Plan: ReSPECT form to be completed with GP. Review if condition changes."

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7. Special Populations and Situations

Paediatric DNACPR

DNACPR decisions in children are ethically and legally complex because children cannot make their own decisions and parental rights are balanced against the child's best interests. [22]

Age-Based Capacity

less than 16 Years:

• Cannot make DNACPR decision themselves (unless Gillick competent)
• Gillick Competence: A child less than 16 can consent to treatment if they have sufficient maturity and intelligence to understand the nature and implications
• However, a Gillick-competent child can consent to treatment but cannot refuse life-saving treatment (parental/court override)

16-17 Years:

• Presumed to have capacity (Mental Capacity Act presumption)
• Can refuse CPR if they have capacity
• However, if refused treatment poses risk of death or serious harm, parents or court can override

Parental Responsibility

Parents can make decisions on behalf of children, but:

• Parental rights exist to protect the child's welfare, not to enable parents to make harmful choices
• If parents demand treatment clinicians believe is futile/harmful, the case can go to court
• Court decides based on child's best interests, not parental wishes

Landmark Cases

Charlie Gard (2017) and Alfie Evans (2018):

• Parents wanted experimental treatment/continuation of life support
• Doctors believed treatment futile and continuation of ventilation not in child's best interests
• High Court and European Court of Human Rights ruled treatment could be withdrawn
• Established that sanctity of life is not absolute; quality of life and suffering are considered

Practical Approach in Paediatrics

Step 1: Multidisciplinary Discussion Paediatrician, intensivist, palliative care, nurse, family

Step 2: Assess Best Interests

• Will CPR work physiologically?
• If it works, what is likely outcome?
• What would recovery/survival mean for the child? (pain, consciousness, ability to interact)
• What are the burdens? (ICU, procedures, separation from family)

Step 3: Involve Parents Share prognosis and recommendations, explore parents' understanding of child's condition and wishes for care.

Step 4: If Agreement Document DNACPR with clear rationale.

Step 5: If Disagreement

• Second opinion
• Mediation (hospital ethics committee, external expert)
• Legal route: High Court declaration (asks court to determine best interests)

Step 6: Emergency Situations If cardiac arrest occurs while discussion ongoing, default is to attempt CPR unless clearly futile and agreement obtained.

Learning Disability and Autism

The Mental Capacity Act applies to people with learning disability, but additional safeguards exist due to historical discrimination. [23]

Presumption of Capacity

Never assume lack of capacity based on diagnosis:

• Mild-moderate learning disability: Usually has capacity for DNACPR decision
• Severe-profound learning disability: May lack capacity, but must be formally assessed

Supported Decision-Making

Provide extensive support:

• Easy-read materials
• Visual aids (pictures of CPR, hospital, home)
• Involve family who know communication style
• Speech and language therapy input
• Allow time to process information

Best Interests Considerations

If capacity lacking, best interests assessment must include:

• Consultation with family, carers, advocates
• Life-long values and preferences
• Quality of life from patient's perspective (not clinician's assumption)
• Avoid assumptions that disability = poor quality of life

Legal Safeguards

Avoid Discrimination (Equality Act 2010):

• DNACPR must not be applied because someone has learning disability
• Must be based on clinical factors (e.g., co-existing severe epilepsy, aspiration, frailty)

COVID-19 Scandal: During the pandemic, some GP practices sent blanket DNACPR letters to patients with learning disabilities. This was ruled unlawful discrimination. [24]

Mental Health and Suicide

Complex intersection of physical illness, mental illness, and capacity.

Suicidal Patient with Physical Illness

Scenario: Patient with metastatic cancer attempts overdose, has ADRT refusing treatment for overdose.

Legal Framework:

• If suicide attempt is driven by mental disorder (depression) that impairs capacity, Mental Health Act may allow treatment despite refusal
• If patient has capacity and decision is not driven by disorder, refusal must be respected
• Differentiating these is extremely difficult

Practical Approach:

• Treat to preserve life in emergency
• Seek urgent psychiatric assessment of capacity
• Explore whether depression is influencing decision
• Consider whether treating depression might change decision
• Seek legal advice if uncertainty

DNACPR in Psychiatric Patients

Scenario: Patient with severe anorexia nervosa, BMI 11, cardiac arrest risk high.

Approach:

• DNACPR decision based on medical futility (CPR unlikely to succeed in severe malnutrition)
• However, must balance against Mental Health Act - if disorder is treatable, treatment should be pursued
• If patient re-fed and stabilizes, CPR may become effective again
• Complex ethical area - involve psychiatry and ethics committee

Dementia

DNACPR in dementia is common but requires careful consideration to avoid discrimination. [14]

Early Dementia

• Patient often has capacity to discuss and decide
• Critical: Have discussion while capacity present
• Document preferences for future

Advanced Dementia (FAST Stage 7)

Clinical Facts:

• Prognosis: Median survival 6 months from FAST 7
• CPR survival: less than 2% to discharge
• Complications of CPR: High (frailty, osteoporosis)
• Post-CPR care: Ventilation, ICU would cause distress to patient who cannot understand

Best Interests Assessment:

• Would CPR work? (No - survival less than 2%)
• If it did work, what would outcome be? (Return to advanced dementia, potentially worsened by hypoxic injury)
• What would burdens be? (ICU environment, restraint, distress)

Conclusion: DNACPR usually appropriate in advanced dementia, but must be individualized and not assumed.

Avoiding Assumptions

❌ "She has dementia, so DNACPR" ✓ "She has advanced dementia (FAST 7), recurrent aspiration pneumonia, bedbound, non-verbal. CPR survival less than 2% and burdens of ICU would outweigh benefits. DNACPR appropriate."

Frailty

Clinical Frailty Scale (CFS) is used to assess frailty (1 = very fit, 9 = terminally ill). [25]

CPR Outcomes by Frailty:

• CFS 1-3 (fit to managing well): Standard CPR outcomes
• CFS 4-6 (vulnerable to moderately frail): Reduced CPR survival (~10%)
• CFS 7-9 (severely frail to terminally ill): Very poor CPR survival (less than 3%)

Use in Decision-Making: Frailty should inform prognostication but not be sole determinant. Consider:

• Acute reversibility (Is the frailty due to acute illness that may improve?)
• Trajectory (Stable vs declining frailty)
• Patient preferences

Caution: CFS was misused during COVID-19 to make blanket DNACPR decisions. Frailty is ONE factor, not THE factor.

Pregnancy

Maternal Cardiac Arrest: Survival of mother and fetus depends on prompt CPR.

Modifications to CPR in Pregnancy:

• Left lateral tilt (relieve aorto-caval compression)
• Perimortem Caesarean section (within 5 minutes if > 20 weeks gestation)

DNACPR in Pregnancy:

• Extremely rare
• Only if mother has terminal condition (metastatic cancer) AND CPR clearly futile
• Fetal viability and gestational age must be considered
• Involve obstetrics, neonatology, ethics committee
• ADRT may not apply during pregnancy

Care Homes

Common Issues:

• Blanket DNACPRs (unlawful)
• DNACPR without resident/family involvement
• DNACPR misinterpreted as "do not send to hospital"

Best Practice:

• Individualized assessment
• Discussion with resident (if capacity) or family
• ReSPECT form to guide emergency care
• Regular review (annual or if condition changes)
• Training for care home staff on meaning of DNACPR

CQC Standards: Care Quality Commission inspects and can rate care homes inadequate if DNACPR decisions not made properly.

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8. Documentation, Review, and Transfer of Information

Documentation Standards

A DNACPR decision is a medical intervention and must be documented to the same standard as prescribing or consenting for surgery.

Essential Components

1. Date and Time Decisions can become outdated; date allows review.

2. Clinical Situation Brief summary of why DNACPR considered: ✓ "Metastatic lung cancer, ECOG 3, prognosis weeks-months, recurrent pleural effusions" ❌ "Cancer"

3. Rationale for Decision

• Futility: "CPR unlikely to restart heart given multi-organ failure"
• Patient choice: "Patient has capacity and refuses CPR"
• Best interests: "Patient lacks capacity. Best interests assessment with family indicates burdens of CPR (ICU, ventilation) outweigh minimal chance of survival given advanced dementia."

4. Capacity Assessment If patient lacks capacity:

• Why? (Unconscious, delirium, dementia)
• 4-part test documented (understand, retain, weigh, communicate)

5. Consultation Who was involved in discussion:

• Patient (if capacity)
• Family members (names and relationship)
• LPA (if appointed)
• IMCA (if no family and lacks capacity)

If NOT discussed with patient:

• Why? (Unconscious, too distressed, would cause harm)
• Evidence for this

6. Patient/Family Response "Patient agreed" "Patient disagreed but understands this is a clinical decision" "Family initially upset but understood after further explanation"

7. Senior Clinician Sign-Off

• Name (printed)
• Signature
• GMC number
• Grade (Consultant, GP, StR)

8. Review Date When should decision be reconsidered:

• Specific date ("3 months"
  • "on discharge")
• Trigger ("if condition improves"
  • "if treatment successful")
• Annual (for stable chronic conditions)

❌ Avoid "indefinite"

Common Documentation Errors

Transfer Across Care Settings

The Portability Problem: DNACPR/ReSPECT must travel with patient, but often gets lost.

Home to Hospital

Community DNACPR:

• Often on GP letter or in "green folder" at home
• Paramedics should check for ReSPECT form
• If found, bring physical copy to hospital

On Hospital Admission:

• ED clinician reviews community DNACPR
• Assess if still valid and applicable
• May need new hospital DNACPR form (different formats)

Hospital to Hospital Transfer

• Handover must include DNACPR status
• Physical form travels with patient
• Receiving team confirms and documents

Hospital to Care Home

• DNACPR/ReSPECT form accompanies discharge summary
• Care home staff briefed
• Copy to GP

Hospital to Home

• Patient/family given copy of ReSPECT
• Copy to GP
• Copy to district nurses
• Advise prominent location (fridge, green folder)

Digital Systems

Electronic Palliative Care Coordination Systems (EPaCCS):

• Some regions have shared electronic records
• GP, ambulance, out-of-hours, hospital can access ReSPECT
• Reduces lost forms

Key Principle: Electronic record does not replace physical form that travels with patient.

Review and Revision

DNACPR is not a one-time decision; it requires review.

When to Review

Mandatory Review:

• Date specified on form reached
• Patient's condition changes significantly (deterioration or improvement)
• Change in care setting (admission, discharge, transfer)
• Patient requests review
• New information emerges (new treatment available)

Optional but Recommended:

• Annual for stable chronic conditions
• After each acute illness episode

Revoking DNACPR

Patient with Capacity: Can revoke at any time, verbally or in writing.

• Document revocation
• Remove/destroy old form
• Complete new form if CPR now for consideration

Clinician Revocation: If clinical situation improves (acute illness treated, patient recovers), DNACPR may no longer be appropriate.

• Discuss with patient/family
• Document reason for revocation
• Ensure all copies removed

Example: Patient admitted with sepsis, DNACPR in place due to multi-organ failure. After 5 days IV antibiotics, patient improving, multi-organ failure resolving. DNACPR reviewed and revoked. Patient now for full escalation.

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9. Audit, Governance, and Quality Assurance

Why Audit Matters

High-profile failures in DNACPR decision-making (Tracey case, COVID-19 blanket DNACPRs) have led to increased scrutiny. Hospitals, GP practices, and care homes must audit DNACPR processes. [24]

Key Audit Standards

1. Individualized Decision-Making

Standard: Each DNACPR decision made on individual assessment, not diagnosis or demographic group.

Audit Question: Are there any DNACPR forms applied to categories (e.g., all care home residents, all patients > 85 years, all patients with learning disability)?

Red Flag: Blanket policies

2. Patient/Family Involvement

Standard (Tracey): Patient consulted unless documented reason consultation would cause harm.

Audit Questions:

• Is there evidence of discussion with patient?
• If not discussed, is there documented rationale?
• If patient lacks capacity, is family/LPA consulted?

Target: > 95% of DNACPR forms have evidence of consultation

3. Capacity Assessment

Standard: If patient lacks capacity, this is documented with specific rationale.

Audit Question: Does the form document why patient lacks capacity (e.g., unconscious, severe dementia, delirium)?

Red Flag: "Lacks capacity" with no detail

4. Senior Clinician Sign-Off

Standard: DNACPR signed by senior decision-maker (Consultant/GP).

Audit Question: What grade is the signatory?

Acceptable: Junior doctor completes form if countersigned by senior within 24-48h

5. Review Date

Standard: All DNACPR forms have review date (not "indefinite").

Audit Question: What % have specific date or trigger?

Target: > 90%

6. Clarity of Rationale

Standard: Reason for DNACPR is clear (futility, patient choice, best interests).

Audit Question: Can an independent reviewer understand why DNACPR was made?

Poor Practice: Vague statements like "frail" or "elderly"

COVID-19 Lessons

During the COVID-19 pandemic, serious failures occurred:

Blanket DNACPRs:

• Some GPs sent letters to all care home residents, patients with learning disabilities, or patients > 70 years applying DNACPR
• This was ruled unlawful (discrimination under Equality Act 2010)
• Led to CQC investigation and apologies from NHS Trusts

Key Lessons:

• DNACPR must never be applied based on diagnosis or demographic alone
• Individual assessment is mandatory
• Convenience (pandemic pressure) does not justify cutting corners

Governance Structures

Trust-Level:

• Resuscitation Committee (multidisciplinary)
• Ethics Committee (complex cases)
• Mortality Review (audit DNACPR in all deaths)
• Training programs for clinicians

Primary Care:

• GP practice policy on DNACPR
• Annual audit of DNACPR in palliative care register
• Training for GPs on communication

Care Homes:

• Named GP lead for end-of-life care
• Six-monthly review of all DNACPR decisions
• Staff training on DNACPR vs broader care decisions

Self-Audit Tool for Clinicians

Before signing a DNACPR form, ask yourself:

1. Capacity: Have I documented specifically why the patient lacks capacity (if applicable)?
2. Consultation: Have I discussed with patient/family? If not, why not?
3. Rationale: Is it clear why DNACPR is appropriate (futility/choice/best interests)?
4. Review: Have I specified when this should be reviewed?
5. Signature: Am I the appropriate senior clinician to sign this?

If you cannot answer "yes" to all, the form is not complete.

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10. Cultural, Religious, and Ethical Considerations

Cultural Perspectives on Death and Dying

Culture profoundly influences how patients and families approach end-of-life decisions. [21]

Truth-Telling and Disclosure

Western Culture (North America, UK, Northern Europe):

• Patient autonomy paramount
• Direct disclosure expected
• Individual decision-making

Non-Western Cultures (Many Asian, Middle Eastern, Mediterranean):

• Collectivist decision-making
• Family protection ("don't tell mother she's dying")
• Respect for elders and authority

Clinical Approach:

• Ask patient: "How much information would you like about your illness?" and "Who would you like involved in decisions?"
• Respect preferences while explaining UK legal framework (patient has right to information if they want it)

Decision-Making Authority

Individualist Cultures: Patient decides (even if family disagrees).

Collectivist Cultures: Family decides together.

Legal Position (UK): If patient has capacity, they decide. Family involvement is for support, not decision-making.

Sensitive Approach: "I understand in your culture the family makes decisions together, and we respect that. In UK law, [patient] has the right to make this decision, but we can absolutely involve you all in the discussion if [patient] wishes."

Religious Perspectives

Christianity

General Principle:

• Sanctity of life valued
• No obligation to pursue "extraordinary" or "disproportionate" means
• Natural death is acceptable

Catholic Teaching:

• Distinguish ordinary (proportionate) vs extraordinary (disproportionate) treatment
• If CPR is futile or excessively burdensome, not required
• Euthanasia forbidden, but allowing natural death permitted

Protestant Views:

• Vary by denomination
• Generally accept withdrawal of futile treatment

Clinical Approach: Offer chaplaincy involvement. Frame DNACPR as "allowing natural death" not "ending life."

Islam

General Principle:

• Life is sacred, from Allah
• "For every life there is an appointed term" (Quran)
• Medical treatment to preserve life is encouraged
• Suffering should be minimized

Views on DNACPR:

• Euthanasia (active ending of life) is haram (forbidden)
• Withdrawal of futile treatment is generally accepted
• "Futility" concept aligns with Islamic teaching (if Allah has appointed the time, we cannot fight against it)

Practical Considerations:

• Involve family (collectivist decision-making)
• Offer Imam consultation
• Emphasize that DNACPR is not euthanasia, but recognition of limits of medicine

Judaism

General Principle:

• Sanctity of life (Pikuach Nefesh - saving life overrides almost all other laws)
• Obligation to pursue medical treatment
• However, suffering should not be prolonged unnecessarily

Orthodox Views:

• Strong emphasis on preserving life
• May object to DNACPR
• Concept of "Goses" (actively dying) - one who is Goses should not have dying prolonged by interventions

Reform/Liberal Views:

• More accepting of DNACPR if treatment futile

Clinical Approach:

• Involve Rabbi
• Explore concept of medical futility ("We are not withholding effective treatment; CPR will not work")
• Discuss "Goses"
• if actively dying, interventions not required

Hinduism

General Principle:

• Belief in reincarnation and karma
• Death is transition, not end
• Quality of death affects next life

Views on DNACPR:

• Generally accepting if treatment futile
• Importance of dying peacefully
• Family involvement important

Practical Considerations:

• Family may wish to perform religious rituals at time of death
• Ensure privacy and space for this

Buddhism

General Principle:

• Suffering is inherent to life
• Middle path (avoid extremes)
• Compassion and reducing suffering

Views on DNACPR:

• Generally accepting
• Prolonging suffering is not aligned with Buddhist teaching
• Peaceful death valued

Sikhism

General Principle:

• Life is gift from Waheguru (God)
• Death is will of God
• Acceptance of God's will

Views on DNACPR:

• If CPR futile, allowing natural death is acceptance of God's will
• Family involvement important

Ethical Frameworks

Four Principles (Beauchamp and Childress)

1. Autonomy Respect patient's right to make decisions.

• In DNACPR: Patient with capacity can refuse CPR
• Requires informed consent (understanding risks/benefits)

2. Beneficence Act in patient's best interests.

• In DNACPR: Do not subject patient to futile, burdensome CPR
• Provide treatments that benefit

3. Non-Maleficence "First, do no harm."

• In DNACPR: Futile CPR causes harm (rib fractures, ICU, prolonged dying)
• DNACPR avoids harm

4. Justice Fair allocation of resources.

• In DNACPR: ICU beds should go to those who can benefit
• However, justice does not override individual best interests

Medical Futility

Physiological Futility: Treatment cannot achieve its physiological goal. Example: CPR cannot restart the heart in multi-organ failure.

Qualitative Futility (controversial): Treatment may restart heart, but outcome is unacceptable quality of life. Example: CPR in severe dementia may achieve ROSC but patient returns to severe dementia with added hypoxic injury.

Ethical Debate:

• Who defines "acceptable quality"?
• Risk of bias (ageism, ableism)
• Patient/family perspective essential

Clinical Approach:

• Be clear which type of futility is being invoked
• For physiological futility: Medical decision (with consultation)
• For qualitative futility: Shared decision with patient/family values central

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11. International Perspectives

United States

Terminology: DNR (Do Not Resuscitate) more common than DNACPR.

Legal Framework:

• State-specific laws (no federal law)
• Advance Directives (similar to ADRT)
• POLST (Physician Orders for Life-Sustaining Treatment) - similar to ReSPECT

Key Differences:

• Stronger emphasis on patient autonomy (patients can demand CPR even if futile in some states)
• Litigation risk higher
• "Slow codes" (half-hearted CPR) ethically problematic but occurred historically

Cultural Note: US culture often emphasizes "fighting" and trying everything, making DNACPR discussions challenging.

Australia and New Zealand

Terminology: NFR (Not for Resuscitation) or DNACPR.

Legal Framework:

• State-based legislation
• Advance Care Directives
• Guardianship Tribunals for disputes

Resuscitation Plans: Similar to ReSPECT - broader goals of care documentation.

Canada

Legal Framework:

• Provincial variation
• Medical Assistance in Dying (MAiD) legal since 2016
• Advance Directives

DNACPR: Similar approach to UK, with emphasis on shared decision-making.

Europe

Variation:

• Northern Europe (Netherlands, Belgium, Scandinavia): High patient autonomy, euthanasia legal in some
• Southern Europe (Italy, Spain, Greece): Family-centered decision-making, Catholic influence
• Eastern Europe: Variable, less developed advance care planning infrastructure

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12. Teaching and Training

Curriculum Integration

DNACPR communication skills should be taught to:

• Medical students (4th-5th year)
• Foundation doctors (mandatory training)
• Core trainees (simulation)
• Specialty registrars (observed discussions)

Simulation-Based Training

Scenario-Based Learning:

• Simulated patient with family
• Practice SPIKES framework
• Receive feedback on communication

Competencies:

• Explain CPR and its limitations
• Assess capacity
• Handle emotion
• Manage disagreement

Assessment

Workplace-Based Assessment:

• Direct Observation of Procedural Skills (DOPS) for DNACPR discussion
• Case-Based Discussion (CbD) for complex decision-making
• Multi-Source Feedback (MSF) from nurses/families

OSCE Stations:

• Breaking bad news (DNACPR discussion)
• Handling conflict (family disagrees)

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References

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2. Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912-1920. doi:10.1056/NEJMoa1109148

3. Girotra S, Spertus JA, Li Y, et al. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes. 2013;6(1):42-49. doi:10.1161/CIRCOUTCOMES.112.967968

4. Venneman SS, Narnor-Harris P, Perish M, Hamilton M. "Allow natural death" versus "do not resuscitate": three words that can change a life. J Med Ethics. 2008;34(1):2-6. doi:10.1136/jme.2006.018317

5. Fritz Z, Malyon A, Frankau JM, et al. The Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a mixed methods evaluation. PLoS One. 2013;8(9):e70977. doi:10.1371/journal.pone.0070977

6. Tracey v Cambridge University Hospitals NHS Foundation Trust [2014] EWCA Civ 822.

7. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990;112(12):949-954. doi:10.7326/0003-4819-112-12-949

8. General Medical Council. Treatment and care towards the end of life: good practice in decision making. London: GMC; 2010.

9. Mental Capacity Act 2005. Chapter 9. London: The Stationery Office; 2005.

10. Department for Constitutional Affairs. Mental Capacity Act 2005 Code of Practice. London: The Stationery Office; 2007.

11. Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3(1):63-81. doi:10.1161/CIRCOUTCOMES.109.889576

12. Ebell MH, Jang W, Shen Y, Geocadin RG. Development and validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) score to predict neurologically intact survival after in-hospital cardiopulmonary resuscitation. JAMA Intern Med. 2013;173(20):1872-1878. doi:10.1001/jamainternmed.2013.10037

13. Wallace SK, Ewer MS, Price KJ, Feeley TW. Outcome and cost implications of cardiopulmonary resuscitation in the medical intensive care unit of a comprehensive cancer center. Support Care Cancer. 2002;10(5):425-429. doi:10.1007/s00520-002-0346-1

14. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA. 2000;284(1):47-52. doi:10.1001/jama.284.1.47

15. Hoke RS, Chamberlain D. Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation. 2004;63(3):327-338. doi:10.1016/j.resuscitation.2004.05.019

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17. Mental Capacity Act 2005, Sections 24-26. Advance decisions to refuse treatment. London: The Stationery Office; 2005.

18. Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005;294(3):359-365. doi:10.1001/jama.294.3.359

19. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665-1673. doi:10.1001/jama.300.14.1665

20. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311. doi:10.1634/theoncologist.5-4-302

21. Searight HR, Gafford J. Cultural diversity at the end of life: issues and guidelines for family physicians. Am Fam Physician. 2005;71(3):515-522.

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Summary for Clinical Practice

DNACPR is a clinical decision that CPR should not be attempted in the event of cardiac arrest. It is not a decision to withhold other treatments.

Legal Framework (UK):

• Mental Capacity Act 2005
• Tracey judgment (2014): Presumption of patient involvement
• Human Rights Act: Article 8 (private life) engaged

Three Foundations:

1. Futility: CPR will not work
2. Patient refusal: Patient with capacity declines
3. Best interests: Burdens outweigh benefits in incapacitated patient

Process:

1. Assess clinical appropriateness (CPR success likelihood)
2. Assess capacity (if lacking, proceed to best interests)
3. Discuss with patient/family (unless harm)
4. Document clearly (ReSPECT form)
5. Senior clinician sign-off
6. Specify review date

Communication (SPIKES):

• Setting: Private, sit down
• Perception: What do they understand?
• Invitation: Permission to discuss
• Knowledge: Clear, compassionate explanation
• Empathy: Respond to emotion
• Strategy: Agree next steps

Red Flags:

• Blanket policies (unlawful)
• No consultation (breaches Tracey)
• Convenience as justification
• "Indefinite" review
• DNACPR = "do not treat" misunderstanding

Documentation Essentials:

• Clinical rationale
• Capacity assessment
• Consultation evidence
• Review date
• Senior signature

Remember: DNACPR is about ensuring appropriate, dignified care at the end of life, not abandonment.

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Image Manifest

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Document Governance

Review Cycle: Annual
Next Review: January 2027
Approving Body: MedVellum Ethics Committee

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End of Document