This mythbuster aims to reduce confusion clarify, signpost and share guidance for providers. It aims help providers manage and maintain effective oversight of DNACPR decisions.
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is also known as:
- Do Not Resuscitate (DNR)
- Do Not Attempt Resuscitation (DNAR).
Throughout this mythbuster we use the term DNACPR for consistency.
Discussions and decisions about resuscitation may be recorded on specific DNACPR forms.
They also may be included on tools such as:
- Recommended Summary Plan for Emergency Care
- Treatment (ReSPECT) and
- Treatment escalation plans (TEP).
Concerns about DNACPR are not new. The COVID-19 pandemic exposed concerns and demonstrated the lasting impact on people.
CQC DNACPR thematic review ‘Protect, Respect, Connect’
In October 2020, the Department for Health and Social Care commissioned us to conduct a thematic review into these concerns. Our review looked at how DNACPR decisions were made in the context of advance care planning. It covered all types of health and care sectors. We included care homes, primary care and hospitals.
Our findings highlighted three areas which needed focus:
- information, training and support
- a consistent national approach to advance care planning
- improved oversight and assurance.
The report includes CQC recommendations in full, including the lead responsible bodies.
Our report showed there were concerns that DNACPR decisions were being applied to groups of people. This was instead of taking each person’s individual circumstances into account. Concerns were around making sure:
- The senior clinician responsible has made the decision in consultation with:
- the person
- where appropriate family/carers
- in line with the Mental Capacity Act 2005
- The decision is based on clinical judgement. It is free from any discrimination and is in line with the Equality Act 2010 and Human Rights 1998.
- The decision is not based on a subjective view of a person’s quality of life.
- The decision has been communicated in an accessible way that meets the patient’s needs.
- Professionals have the time, support and training to be able to have the sensitive and ongoing conversations needed to take the patient’s preferences into account.
- The patient and care workers understand the patient’s legal rights.
The Human Rights Act 1998 and Mental Capacity Act 2005 provide the legal basis for DNACPR decision-making in England and Wales. Local policymakers are responsible for effective systems to record and communicate resuscitation decisions.
All establishments responsible for discussions and decisions about cardiopulmonary resuscitation should have a policy about DNACPR decisions. This includes:
- general practices
- care homes
- ambulance services.
The policy must be readily available and understood by all relevant staff.
Person centred care
Patients must always be at the centre of their care. Including advance care planning and DNACPR decisions. Everyone needs to have access to personalised support around DNACPR decisions. This should be equal, non-discriminatory and support their human rights.
Patients, families and representatives need to be supported, as partners in personalised care. They should understand what good practice looks like for DNACPR decisions. They should all share the same understanding and expectations for DNACPR decisions.
Clinicians, professionals and workers must have the knowledge, skills and confidence to speak with the patient about, and support them in, making decisions about resuscitation.
Effective communication is essential. Decisions about CPR must be well made. They must be clearly understood by everyone involved. There should be communication with the patient and those close to them (unless they have requested confidentiality). This should be:
It should include:
- provision of information
- checking their understanding of what has been explained to them.
Resuscitation Council UK guidance on DNACPR and CPR decisions includes information for patients and their families.
As part of the decision-making process, the patient should be made aware that DNACPR is about CPR only. Providers should tell patients that they will still receive any other appropriate care and treatment. This is in line with any advance directives or treatment escalation plans in place.
For many patients, anticipatory decisions about cardiopulmonary resuscitation are best made in the wider context of advance care planning. This is before a crisis requires a hurried decision in an emergency setting. The General Medical Council (GMC) has published guidance for providers on decision-making models. The guidance explains what options are available for patients with and without capacity.
Every decision must be made based on a careful assessment of each patient’s situation. Decisions must never be dictated by ‘blanket’ policies. Decisions must be free from any discrimination. For example, disability or age. Accessible information should be used. This may include easy read, translation or interpretation services if needed.
Decisions should be frequently reviewed based on the person’s individual circumstances. Reviews allow a change in decision (in either direction) following the person’s clinical progress, or lack of. Joint guidance from the British Medical Association (BMA), Resuscitation Council UK and Royal College of Nursing (RCN) has been published on decisions about DNACPR.
Decisions about CPR should be reviewed at appropriately frequent intervals. A future date of review should be planned and recorded. Specifically, whenever changes occur in a person’s condition or in their expressed wishes. This applies to a decision that CPR is appropriate as well as to a DNACPR decision. The frequency of review should be determined by the healthcare professional responsible for their care. It will be influenced by the clinical circumstances of the patient. Local policies should include some general safeguards for ensuring:
- review occurs appropriately
- any changes in CPR status are discussed and communicated properly.
DNACPR decisions and conversations should be undertaken by members of the healthcare team who are:
- appropriately trained
Training should give health and care professionals the knowledge, skills and confidence to talk to the patient and their relatives or carers about advance care planning and DNACPR decisions.
Discussions may include the level of care and treatment patients wish to receive as they reach the end of their lives. Training should help professionals to make sure they are holding these conversations at the appropriate time. They should always take a personalised approach. This puts the patient at the centre of their care. It ensures that their human rights and rights to equal treatment are protected.
BMA/RCN guidance states that organisations providing healthcare must make sure their clinical staff have up-to date knowledge and adequate training to:
- make appropriate decisions about CPR
- give relevant information to patients and those close to them
- communicate effectively with patients and those close to them
- support the involvement of patients and those close to them through sensitive discussions
- undertake appropriate review of decisions about CPR.
ReSPECT/Advance care planning/Treatment Escalation plans
The use of tools including:
- advance care planning
- Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)
- Treatment escalation plans (TEP)
These tools offer patients the opportunity to plan their future care and support. This includes medical treatment and resuscitation options, while they have the capacity to do so.
Not everyone will want to make decisions in advance planning and future care.
Support may be especially relevant for:
- Patients at risk of losing mental capacity. For example, through progressive illness.
- Patients whose mental capacity may fluctuate. For example, those living with a mental health condition.
GPs and other practice staff may be asked to support this process.
The Royal College of Nursing (RCN) has published guidance and resources on Advance Care Planning. The National Institute for Health and Care Excellence (NICE) has produced a quick guide for registered managers of care homes and home care services.
The ReSPECT process is used to encourage a conversation to create a recorded summary of personalised recommendations for a person’s clinical care in a future emergency, if they do not have capacity to make or express choices.
ReSPECT or DNACPR forms are not legally binding. GPs will need to use clinical judgment. They may decide not to follow the recommendations on a ReSPECT form. The forms are a guide to immediate decision-making. Recommendations are made through conversations between the patient, their families, and health and care professionals. They are recorded on the appropriate form. Patient preferences and clinical recommendations are recorded on the non-legally binding form. The form can be reviewed and adapted if circumstances change.
Resuscitation Council UK has published ReSPECT guidance for healthcare professionals.
Patients may opt to complete an advance decision form. An advance decision is a decision patients can make to refuse a specific type of treatment at some time in the future. The scope of treatments the patient is deciding to refuse will be in the advance decision. Advance decisions are sometimes known as an advance decision to refuse treatment, an ADRT, or a living will.
NHS England has published guidance on the end of life care and advanced decisions to refuse treatment (advance decision living will). It states that an advance decision is legally binding as long as it:
- complies with the Mental Capacity Act
- is valid
- applies to the situation.
As the advance decision is binding, it takes precedence over decisions made in the patient’s best interest by other people.
Record keeping and communication
There must be full records of conversations with, and decisions agreed with, the patient, their families and representatives that support them to move around the system well. These records should be accessible to those involved in the patients care. Records should show discussions about patients’ needs, wishes and preferences have been completed. The Medical Defence Union (MDU) guidance and advice document suggests providers should:
- Make a clear note in the patient's records about the DNACPR discussion and your reasons for recommending a DNACPR order.
- Ensure DNACPR decisions are communicated to everyone involved in the patient's care. For example, care home staff and the nursing team.
The presence of a ReSPECT or DNACPR form should be clearly highlighted in the patient’s clinical record for all who access it.
Moving between services
Patients need to have more positive and seamless experiences of care, when moving around the health and care system. This includes DNACPR decisions. Recorded decisions about CPR should accompany a patient. They should be accessible to those contributing to the patients care, when they move from one setting to another.
GMC guidance suggests providers make sure that all those consulted, especially those responsible for delivering care, are informed of the decisions. They are clear about the goals and the agreed care plan. Unless the patient indicates that particular individuals should not be informed.
GPs and practice staff should use available systems and arrangements, so the agreed care plan is shared with:
- the healthcare team
- other health professionals involved in providing the patient’s care.
This is particularly important when patients move across different care settings (hospital, ambulance, care home) and during any out-of-hours period.
Failure to communicate some or all relevant information can lead to inappropriate treatment.
Leadership, governance and assurance
There should be oversight of advance care planning systems, end of life care and DNACPR decisions. Providers should have systems in place to be assured of the quality of DNACPR decisions.
Systems should be in place to evaluate and learn from incidents relating to DNACPR decision making processes, to improve the patient’s experiences.
Providers should foster a culture where complaints and concerns about DNACPR decisions can be challenged openly.
Integrated care systems need to be able to monitor and assure themselves of the quality and safety of DNACPR decisions made by providers working within their system. Health and social care providers must make sure all workers understand how to speak up. They should feel confident to speak up and be supported and listened to when they speak up.
When we inspect
We continue to seek assurance that patients are at the centre of personalised, high-quality and safe experiences of DNACPR decisions, that protect their human rights.
We will look for evidence to show that:
- Decision making processes are in line with the Mental Capacity Act 2005.They are based on clinical judgement and are free from any discrimination.
- Decisions have been communicated in an accessible way. They meet the patient’s needs and are documented appropriately.
- Practice staff take the patient’s preferences into account. They have the time, support and training to be able to have these sensitive and ongoing conversations.
- The patient's legal rights are understood by patients, their families and care workers.
- Effective leadership, governance and assurance processes are in place.
We use Regulations when we review if the practice is:
- well led.
This mythbuster relates to:
- Regulation 9 (Person centred care)
- Regulation 10 (Dignity and respect)
- Regulation 11 (Need for consent)
- Regulation 12 (Safe care and treatment)
- Regulation 13 (Safeguarding service users from abuse and improper treatment)
- Regulation 17 (Good governance)
It is part of our key lines of enquiry (KLOEs). In particular:
- S1 Safeguarding and protection from abuse
- S3 Safe care and treatment
- E1 Assessing needs and delivering evidence-based treatment
- E3 Staff skills and knowledge
- E4 How staff, teams and services work together
- E6 Consent to care and treatment
- C2 Involving people in decisions about their care
- C3 Privacy and Dignity
- R1 Person-centred care
- R2 Taking account of the needs of different people
- Decision-making and mental capacity (NICE guideline, including implementation resource).
- Mental Capacity Act Code of Practice (available from Office of the Public Guardian).
- Planning for your future care: a guide (An information source for people considering advance care planning - NCPC/University of Nottingham/National End of Life Care Programme).
- My future wishes: Advance care planning for people with dementia in all care settings (NHS England).