Summary

Cardiopulmonary Resuscitation (CPR) is a highly invasive medical treatment initiated in the event of cardiac arrest. It involves vigorous chest compressions, electric shocks (defibrillation), and artificial ventilation. A DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decision is a clinical determination that this specific treatment should not be attempted.

Crucially, it is NOT a decision to stop active care. It is a decision to avoid a specific, likely futile, and potentially harmful intervention at the point of death. The modern phrase "Allow Natural Death" captures the intent more compassionately.

Since the landmark Tracey vs Cambridge (2014) ruling, the legal landscape has shifted significantly. Clinical paternalism ("Doctor knows best") has been replaced by a mandatory requirement to consult patients (or their advocates) unless doing so would cause demonstrable physical or psychological harm.

Key definitions

• DNACPR: Do Not Attempt Cardiopulmonary Resuscitation.
• ReSPECT: Recommended Summary Plan for Emergency Care and Treatment (The modern standard).
• ADRT: Advance Decision to Refuse Treatment (Legally binding "Living Will").
• LPA: Lasting Power of Attorney (Health & Welfare).

The 3 Core Pillars of Decision Making

1. Clinical Possibility: Is there a realistic chance CPR will restart the heart and lead to discharge?
2. Patient Choice: Does the patient (with capacity) refuse CPR?
3. Best Interests: In a patient lacking capacity, would the burdens of CPR outweigh the benefits?

The law surrounding end-of-life decisions is codified in the Mental Capacity Act (2005) and the Human Rights Act (1998).

The Mental Capacity Act (2005)

This is the bedrock of all decision making.

• Principle 1: Assume Capacity. (Unless proven otherwise).
• Principle 2: Supported decision making. (Do everything to help them understand).
• Principle 3: Unwise decisions are allowed. (Autonomy allows "bad" choices).
• Principle 4: Best Interests. (If capacity is lost, act in their best interests).
• Principle 5: Least restrictive option.

The 4-Stage Capacity Test

To have capacity to decide on CPR, the patient must:

1. Understand the information (CPR involves chest compressions, shocks, ventilation).
2. Retain that information long enough to decide.
3. Weigh the risks and benefits (survival chance vs rib fractures/brain damage).
4. Communicate their decision (speech, sign, blink).

Essential Case Law

1. Tracey v Cambridge University Hospitals (2014)

• The Facts: Janet Tracey had a DNACPR placed without her being told. She died. The family sued.
• The Ruling: Mrs Tracey's Article 8 human rights (Right to private life) were breached.
• The Precedent: You MUST tell the patient about a DNACPR decision unless you can prove that the conversation itself would cause physical/psychological harm (Distress is not harm).

2. Winspear v City Hospitals Sunderland (2015)

• The Facts: Mr Winspear lacked capacity. A DNACPR was put in place at 3am without calling his mother (who had LPA?), because it was "too late to call".
• The Ruling: Convenience is not an excuse. You must consult those close to the patient at the earliest practicable opportunity.

3. Burke v GMC (2005)

• The Ruling: Patients can demand effective treatments, but they cannot demand futile treatments. A doctor is not legally obliged to provide CPR if it is clinically futile.

Criteria for DNACPR

1. CPR is unlikely to succeed: The underlying condition is irreversible (e.g., metastatic cancer, multi-organ failure). CPR would only prolong the dying process.
2. CPR might succeed, but outcome is unacceptable: The patient might survive the arrest but would suffer severe hypoxic brain injury or non-survivable trauma (e.g., severe frailty/osteoporosis).
3. Patient's informed wish: A competent patient declines CPR.

Who Makes the Decision?

• Scenario A: Futility: The Senior Doctor makes the decision. They consult the patient/family to explain, but they do not need permission. (You cannot demand a treatment that doesn't work).
• Scenario B: Quality of Life: The Doctor and Patient/Family decide together. This is a value judgement.

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form has replaced the old "Red Form" DNACPR in many UK trusts. It is broader and more holistic.

Section 1: Summary of Diagnosis

• Why are we making this plan?
• Example: "Severe COPD (FEV1 30%), Frailty Score 7, Recent aspiration pneumonia."

Section 2: Personal Priorities (The "What Matters" Box)

• This is the most important box.
• Example: "I want to be at home with my dog. I do not want tubes or machines."
• Example: "I want to live long enough to see my grandson born next month."

Section 3: Clinical Recommendations

• Focus of Care Scope:
  • Scale: "Prioritise Sustenance of Life" <---> "Prioritise Comfort".
  • Specifics: Ward based care? ICU? Antibiotics? Fluids?
• CPR Status:
  • RED: CPR attempts recommended.
  • BLUE: CPR attempts NOT recommended.

Section 4: Capacity & Representation

• Who was involved?
• Does the patient have capacity?
• If not, is there an LPA or IMCA?

Also known as a "Living Will".

Requirements for Validity

To be legally binding for life-refusing treatment, an ADRT must:

1. Be Written: Verbal is not enough for life-sustaining refusal.
2. Be Signed: By patient and a witness.
3. Specific Statement: Must state "Even if life is at risk".
4. Capacity: Must have been made when the patient had capacity.

Clinical Impact

• If a paramedic arrives at an arrest and sees a valid ADRT refusing CPR, they MUST stop.
• Continuing CPR in the face of a valid ADRT is Battery (Civil and Criminal assault).

ADRT vs LPA

• An ADRT is a document.
• An LPA (Lasting Power of Attorney) is a person.
• Hierarchy: If an ADRT was made after the LPA was appointed, the ADRT wins. If the LPA was appointed after the ADRT, the LPA wins (assuming the patient gave them authority to override).

Talking about death is the hardest part of medicine.

1. Setting

• Sit down. Eye level.
• Bleeps off.
• Correct people present (does the patient want their daughter there?).

2. Perception

• "What do you understand about your heart condition and your frailty?"
• Test the water: Do they know they are dying?

3. Invitation

• "Is it okay if we talk about emergency treatment plans today? It's routine for everyone, but important."

4. Knowledge (The "F" Word - Futility)

• Don't say: "Do you want us to jump on your chest?" (Too brutal).
• Don't say: "Do you want us to bring you back?" (Implies success).
• Do say: "I am worried that your heart is now very weak. If it were to stop naturally, it would be because your body has reached its limit. I don't believe that trying to restart it with CPR would work, and it would involve a violent physical ordeal (broken ribs)."

5. Empathy

• Silence.
• "I know this is hard to hear."

6. Strategy

• "So, we will make a plan to Allow Natural Death when the time comes. We will focus on keeping you comfortable, pain-free, and with your family."

The law is different for children.

Best Interests

• In paediatrics, "Sanctity of Life" is weighed heavily.
• However, subjecting a child with a severe neurodegenerative condition to futile CPR is considered unethical.

Conflict (Charlie Gard / Alfie Evans Cases)

• If parents demand treatment that doctors believe is futile/harmful:
  • Mediation first.
  • Second opinion.
  • High Court: The ultimate arbiter. The Court decides based on the Child's best interests, not the Parents' rights.

Can you put a DNACPR on a suicidal patient?

• The Paradox: A patient attempts suicide (Overdose). They have an ADRT refusing treatment.
• The Law: If the decision is driven by a "Mental Disorder" (Depression) which impairs their capacity to weigh the decision, the Mental Health Act allows treatment of the consequences of the suicide attempt.
• However: If a patient has a physical illness (Cancer) AND Depression, proving the refusal is due to the depression is complex. Seek legal advice.

A DNACPR form is a legal document. Errors invalidate it.

Common Pitfalls

1. "Review Date: Indefinite": Bad practice. Even for permanent conditions, review "If condition changes" or "Annually".
2. Missing Capacity Assessment: You must document why you think they lack capacity (e.g., "Unconscious", "Severe Dementia").
3. Missing Consultation: If you didn't talk to the family, you MUST document why (e.g., "No next of kin", "Emergency situation").

The "Travel" Rule

• The form belongs to the patient.
• It must move with them (Home -> Ambulance -> Hospital -> Hospice).
• "Green Envelope": Many community trusts use a recognisable green envelope so paramedics can find it on the fridge.

Death is not just biological; it is spiritual.

• Islam: Life is sacred. "Euthanasia" is forbidden. However, withdrawing futile treatment is permitted ("To every life there is a term").
• Judaism: "Pikuach Nefesh" (Saving a life) is paramount. Some Orthodox interpretations struggle with the concept of "do not resuscitate".
• Christianity: Generally accepts that "officious" (over-zealous) treatment need not be pursued if burdensome.
• Approach: "Does your faith have any specific teachings about the end of life that we should know?"

How do we ensure we aren't breaking the law (like during COVID-19)?

• The COVID-19 Audit: During the pandemic, some GPs applied "Blanket DNACPRs" to care homes. This was ruled Unlawful. Each decision must be individual.
• CQC Requirement: Care Quality Commission inspections check that DNACPRs are:
  1. Individualized.
  2. Signed.
  3. Dated.
  4. Have evidence of discussion.

Case 1: The "Frail" 90-Year-Old

Scenario: A 93-year-old lady with advanced dementia and frailty is admitted with pneumonia. She lacks capacity. Her daughter says "She is a fighter, do everything." Assessment: CPR success rate <1%. Risks: rib fractures, hypoxic brain injury, undignified death. Discussion: Explained to daughter that CPR is not a menu option here as it will not work. The daughter is distressed. Resolution: Issued DNACPR on grounds of clinical futility. Documented "Discussion with daughter; she disagrees but decision made in best interests to avoid harm." Legal: This is lawful. The daughter was consulted. She cannot demand futile treatment.

Case 2: The "Young" Capacity Case

Scenario: A 24-year-old man with Motor Neurone Disease (MND). He uses a wheelchair but has full mental capacity. He says "If my heart stops, let me go. I don't want to be on a ventilator." Action:

1. Verified capacity (Understand/Retain/Weigh/Communicate).
2. Completed ReSPECT form.
3. CPR Status: Not for CPR.
4. Recorded rationale: "Patient refusal". Note: Even though CPR might "work" (restart heart), his Refusal (Autonomy) trumps Medical Benefit.

How to fill the form without getting sued.

Section 2: "What Matters to Me"

• Bad Example: "Wants to be comfortable." (Vague).
• Good Example: "Fears hospital admission. Wants to remain in Nursing Home. Willing to accept IV antibiotics if they can be given at home. Granddaughter wedding in June is a priority."

Section 3: "Clinical Recommendations"

• Left Hand Side (Life):
  • Tick here if patient is for full escalation (e.g., ICU, Intubation).
  • Specify limits: "For trial of NIV but not Intubation."
• Right Hand Side (Comfort):
  • Tick here if focus is symptom control.
  • "For oral antibiotics, subcutaneous fluids, but not IVs or admission."

Section 6: Clinician Signature

• Must be a Senior Clinician (Consultant or GP).
• Junior doctors can fill it in, but a Senior must countersign within 24-48 hours.

For every DNACPR form you sign, ask these 5 questions:

1. Capacity: Have I documented specifically why they lack capacity? (e.g., "Disoriented to time/place, cannot retain information for >10 seconds").
2. Consultation: Have I spoken to the Next of Kin? If not, have I documented why? (e.g., "Patient unbefriended - IMCA referral made").
3. Indefinite?: Have I avoided the word "Indefinite"? (Use "12 months" or "On discharge").
4. Rationale: Is the reason "Futility" (Medical) or "Quality of Life" (Value judgement)? If QoL, is the patient in agreement?
5. Placement: Is the form physically with the patient?

Scenario: The "Guilty" Daughter

Daughter: "You have to try! I can't be the one who kills her." Doctor: "I hear how heavy this feels. But I need you to know: you are not making this decision. The medical condition is making the decision. We are asking you to tell us what your mother would say, not to take the burden of the decision yourself. The decision to not restart her heart is mine, based on the fact that it won't work."

Scenario: The "Miracle" Believer

Relative: "We are praying for a miracle. Don't write him off." Doctor: "We respect your faith. However, my medical duty is to ensure I don't assault him with a treatment that causes harm without benefit. We can pray for a peaceful transition, or a spontaneous recovery, but CPR is a physical act that I cannot justify medically."

• CPR: Cardiopulmonary Resuscitation.
• ROSC: Return of Spontaneous Circulation (Restarting the heart).
• Hypoxic Brain Injury: Brain damage caused by lack of oxygen during arrest.
• Futility: Treatment that provides no physiological benefit or fails to achieve the patient's goals.
• LPA: Lasting Power of Attorney.
• IMCA: Independent Mental Capacity Advocate.
• ReSPECT: Recommended Summary Plan for Emergency Care and Treatment.

Review Cycle: Annual Next Review: Dec 2026 Approving Body: MedVellum Ethics Committee