What is a do not attempt resuscitation decision (DNACPR)?

What is a do not resuscitate decision and how is such a decision made? When it comes to DNACPR (also referred to as DNAR), this article covers definitions and the steps involved before a decision about resuscitation can be made.

What is DNACPR/DNAR?

DNACPR stands for Do Not Attempt Cardiopulmonary Resuscitation.

It is also referred to as DNAR (Do Not Attempt Resuscitation) or DNR (Do Not Resuscitate). 

The purpose of a do not resuscitate decision is to inform healthcare professionals that cardiopulmonary resuscitation (known as CPR) should not be given if you suffer a cardiac arrest (your heart stops) or you stop breathing. 

What is CPR?

CPR means cardiopulmonary resuscitation. This a physical intervention that attempts to restart a person’s heart when it has stopped or get them breathing again if they are not. 

CPR can, for example, involve placing hands on a person’s chest to make chest compressions or using a defibrillator machine which gives electrical shocks to the chest.  

Why shouldn’t everyone be given CPR? 

• It may not be in everyone’s best interest to have CPR. 
• Not everyone wants to have CPR and therefore their wishes must be respected. CPR can rob them of what they consider to be a dignified death.
• CPR may also not be appropriate if a person’s heart and breathing stop because they are dying from an irreversible condition.  
• CPR may not help you live longer. This may be because your organs are too damaged or CPR may prolong or cause suffering when you are approaching the end of your life.  

What is the rule for do not resuscitate order (DNAR)?

A Do Not Attempt Resuscitation (DNAR) decision may be made because someone is so unwell from an underlying illness, that CPR will not prevent their death. Sometimes healthcare teams must decide for individuals whether or not to give CPR.They may attempt to involve a person’s loved ones in this decision. 

The law does not require your consent to a DNACPR/DNAR. The law does, however, demand that you have the right to be involved in a do not resuscitate decision and made aware of a doctor’s decision.

Who can make a DNACPR decision?

A DNACPR/DNAR decision can be made by you or a doctor.  

You can decide in advance to refuse CPR. Anyone who has mental capacity can refuse CPR if they want and they can decide this at any time in their life. 

Can a DNACPR decision be made without my consent?   

• A doctor can make a DNACPR/DNAR decision even if you do not agree with it. 
• You should be consulted before a do not resuscitate decision is made.
• Your doctor should explain what DNACPR/DNAR is and why they think CPR is not suitable for you.
• You must be told that a DNACPR/DNAR decision has been recorded for you.

How is a DNACPR decision recorded?  

A DNACPR/DNAR decision is recorded on a form. Your doctor can complete a DNACPR form to indicate your wishes. 

Where is a DNACPR form kept? 

• A DNACPR form is placed in your medical records.
• It can also be kept in a care home if you live there or be with you, if you live at home.
• You must be informed if a do not resuscitate form has been put in your medical records.
• You should tell your loved ones about it and where it is kept.

How long does a DNACPR form last?

• A DNACPR can be written without an end date.
• It is a good idea for a DNACPR decision to be reviewed whenever a person’s condition changes and before any move between care settings.
• A DNACPR form can be written by a doctor for a specific time period. However, after that period (if a do not resuscitate decision still remains appropriate) a new form should be written. 

Do I have to inform my family of a DNACPR decision?

You do not have to tell your family about a don not resuscitate decision but if you want to be sure that your DNACPR decision is respected, your loved ones should know about the decision. They should know where the DNACPR has been recorded.

What do I do if I change my mind about a DNACPR decision? 

You can change your mind about your DNACPR decision at any time. If you do, tell your doctors to ensure your DNACPR form is marked as no longer valid. 

What steps are taken before a DNACPR is carried out?

• The decision must be made on an individual basis and must be based on your health and needs as an individual. 
• The CQC has published guidance (December 2022) for healthcare professionals and care workers about DNACPR. 
• The CQC recommends doctors ask about your wishes and preferences in relation to DNACPR in an ‘accurate’, ‘clear’, ‘honest’ and ‘timely’ manner.
• All settings responsible for CPR decisions (including care homes, general practices, hospitals and ambulance services) must have a policy about DNACPR decisions which is understood by staff.

What does the CQC say about DNACPR?  

The CQC states: 

• Must be based on clinical judgement. It is free from any discrimination and is in line with the Equality Act 2010 and Human Rights 1998.
• Must not be based on a subjective view of a person’s quality of life.
• Must be communicated ‘in an accessible way’ that meets the person’s needs.
• Professionals have the time, support and training to have the conversations needed to consider a person’s wishes.
• The patient and care workers must understand the person’s legal rights.

Is a DNACPR form legally binding?

• A DNACPR form is not legally binding. 
• If you wish to make your wishes legally binding, then you must write an Advance Decision to Refuse Treatment (ADRT).  

An ADRT is (as defined in the Mental Capacity Act 2005 – England & Wales) a legally binding document that the person has drawn up when they had the capacity to make decisions.

An ADRT explains that you want to refuse CPR (or other treatments). 

Will I still receive care if a DNACPR decision has been made? 

You will continue to have other treatments and care you need. Only CPR will not be attempted.

What can I do if I disagree with a DNACPR decision?

• You cannot demand CPR. The law does not require your consent to a DNACPR. The law demands you have the right to be involved in and informed of a doctor’s DNACPR decision.
• If you disagree with a DNACPR decision made by a GP, you can follow the general practice’s complaints procedure. If you find the general practice’s response unacceptable, you can complain to NHS England.
• You can also ask for a second opinion about DNACPR from another doctor. If the DNACPR form was made by a doctor in a hospital, follow the hospital’s complaints procedure.  
• If you do not have mental capacity, your loved ones or someone with the legal power to represent you e.g. a Lasting Power of Attorney  https://www.carehome.co.uk/advice/power-of-attorney-in-england-and-wales can raise concerns about a DNACPR for you.

Do I have a right to know if my relative has a DNACPR?

If the person has capacity and does not want you to know about their care, you have no right to know about a DNACPR. 

When is a DNACPR not appropriate?

DNACPR decisions must not be made for a group of people at the same time. 

For example, DNACPR decisions must not be made for all residents living in a care home or for a group of people over a certain age. This is against the law. If someone has dementia, a learning disability or autism, these are not valid reasons to put a DNACPR on someone’s record.

In 2020 (during Covid-19 pandemic’s first wave), the charity Age UK received a high number of calls to its helpline from older people in Scotland who had been contacted unexpectedly by their GP practice and asked to consent to a DNACPR form. 

Age Scotland heard about cases of poor practice, including:

• All residents in some care homes having DNACPR orders applied to them unilaterally, without consultation.
• Calls made to people with dementia, (excluding their Power of Attorney) who do not remember agreeing to a DNACPR. 
• DNACPR forms being put in hospital discharge notes without a patient’s knowledge, even after they had said they did not want a DNACPR.

The charity stated: ‘The use of DNACPR during the pandemic has been a source of distress for many older people.

Additionally, as a result of media coverage we secured highlighting the issue, several older people contacted us to make us aware of their negative experiences of DNACPR from before the pandemic’.

Some care home residents were wrongly given DNRCPR decisions at the start of the Covid-19 pandemic, which resulted in avoidable deaths, the Care Quality Commission (CQC) concluded in its report ‘Review of do not attempt cardiopulmonary resuscitation decisions during the Covid-19 pandemic’ (published November 2020.)

Blanket approach to DNACPR ‘unlawful’

Amnesty International’s report ‘As if expendable: the UK government’s failure to protect older people in care homes during the Covid-19 pandemic’ (published 4 October 2020), stated: ‘The blanket imposition of DNACPR notices without proper patient involvement is unlawful. 

‘Care home managers reported to Amnesty International and to media cases of local GP surgeries or Clinical Commissioning Groups (CCGs) requesting them to insert DNAR forms into the files of residents as a blanket approach. 

‘Asked about any blanket approaches to DNARs, one care home owner in the north of England told Amnesty International, “We had a letter to that effect from the practice. I refused to sign it and handle it like that.”

Another reported that they were asked to insert DNAR forms into a number of residents’ files.’  

Referring to DNACPR, Age UK stated: ‘Although clinicians will use their judgement to decide whether to make a DNACPR decision, this discussion between patient and clinician should always take place, and both parties should be well informed about it in advance.’    

Advance Care Planning is the discussion you have with healthcare professionals and your loved ones about what future care you would like. For details about Advance Care Planning click here