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What is the purpose of a DNACPR recommendation?

A DNACPR recommendation provides immediate guidance to healthcare professionals on the best course of action should someone experience cardiac arrest or die suddenly.

Terminology: how should we talk about DNACPR?

A decision to recommend that cardiopulmonary resuscitation (CPR) is not attempted should be called a recommendation. To call them ‘DNACPR notices’ or ‘DNACPR orders’ implies a recommendation about future CPR is inflexible and will be followed, regardless of the circumstances at the time of the emergency. A DNACPR recommendation is only that, whether contained in a stand-alone DNACPR form, or contained in a broader advance care plan or emergency care and treatment plan. A DNACPR recommendation serves the sole, important function of informing clinical decision-making at the time of the emergency.

Is a DNACPR recommendation legally binding?

No it is not. A DNACPR recommendation is a guide for clinicians who are responding to the emergency and have to make a decision about whether to start CPR.

Should a patient be involved in the conversation about DNACPR if they have capacity?

Yes. If a patient has capacity, the courts in England and Wales have made it clear the individual must be involved in a conversation about CPR – unless to do so is likely to cause them to suffer physical or psychological harm.

It is important to understand a decision on whether or not to make a DNACPR recommendation is ultimately a clinical one, rather than one for the patient.

If the patient wishes to refuse CPR, they should be supported to make an advance decision to refuse treatment (ADRT).

Clinicians must be clear in their conversation with the patient why they think CPR should not be recommended. It could be because they think it would be futile, as it would not work; or it could be because they think CPR would not be in the patient’s best interests.

In either case, the patient can ask for a second opinion, but the clinical team does not have to obtain a second opinion if the decision that CPR would be futile was reached on a robust, multidisciplinary basis.

If a patient has a DNACPR recommendation recorded on a form and goes into cardiac arrest – but that DNACPR form is not available – should CPR be started?

If a patient is known to have a DNACPR recommendation, it is appropriate not to perform CPR, providing the clinician is confident the recommendation is still applicable and pertinent to the patient they are dealing with. The clinician at that point can have a reasonable belief that they are acting in the patient’s best interests.

Should a recommendation about CPR be discussed as part of other emergency care and treatment?

Yes, CPR recommendations should be discussed with the patient as part of a conversation about their overall goals of care and treatment. This ensures the recommendation about CPR is put in context. Recommendations about DNACPR should not be made in isolation for two reasons:

What if a person lacks capacity to participate in a conversation and has no family or anyone close to them?

If the decision-making is taking place in hospital they should arrange for an independent mental capacity advocate (IMCA) to be involved. However, the duty to arrange for an IMCA does not apply in a setting where they are not being cared for or treated by an NHS body. However, in either case, where the person is unbefriended, medical professionals need to be astute to try to identify all relevant evidence for what the person would wish.

This is an abridged version of an article at rcni.com/dnacpr-guide

Further information

Resuscitation Council UK resus.org.uk

RCN (2016) Consultation Response: Emergency Care and Treatment Plan (ECTP) rcn.org.uk/About-us/Our-Influencing-work/Policy-briefings/conr-0616

Mind: Advocacy in Mental Health mind.org.uk/information-support/guides-to-support-and-services/advocacy/imcas/