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‘Do not attempt resuscitation’ decisions (DNACPR)

Thinking about whether you would want to be resuscitated in the event of an emergency is a complex issue. We tackle the confusion around DNACPR decisions, and explain how they are made.

In this article
What is a DNACPR decision? Who can make a DNACPR decision? What is cardiopulmonary resuscitation (CPR)? Why would a DNACPR decision be needed?
Are DNACPR forms legally binding? Telling others about your DNACPR form Improving the DNACPR decision process

What is a DNACPR decision?

If your heart stops beating or you stop breathing, medical professionals may attempt an emergency procedure to bring you back to life. But in some circumstances this may do more harm than good.

A ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decision instructs medical staff on whether or not they should attempt to resuscitate you. There is often confusion about how these decisions are made and when they can be used.

A DNACPR decision is a written instruction that tells medical staff not to attempt to bring you back to life if your heart stops beating or you stop breathing. It may also be referred to as:

  • a ‘do not resuscitate’ (DNR) order
  • a ‘do not attempt resuscitation’ (DNAR) decision
  • a DNACPR order.

These terms all refer to the same procedure. 

A doctor is likely to recommend a DNACPR decision if they feel that resuscitation is unlikely to be successful or may even cause you harm.

The decision is usually recorded on a special DNACPR form, completed by a doctor. The form makes it easy for health professionals to quickly recognise a DNACPR decision in an emergency. The form only covers CPR, so if you have a DNACPR form you’ll still be given other treatment and care to ensure you are pain-free and comfortable.

In the past, this process was often called a ‘do not resuscitate’ order. But this phrase is now considered inaccurate, as there’s no guarantee that resuscitation will be successful and the decision is actually about whether it should be attempted in the first place.

Who can make a DNACPR decision?

In the past only a doctor could issue a DNACPR form. But other healthcare professionals, such as nurses and paramedics, may now also issue one, especially if a patient has specifically asked them to write a DNACPR form and add it to their notes. In most circumstances they should do this in consultation with you or those close to you – unless they believe that discussing it with you could lead to harm.

If you decide that you don’t want to receive cardiopulmonary resuscitation (CPR) in future, you can make this known to your doctor or medical team. As long as you have mental capacity, they should take your wishes into consideration. If you don’t want to receive CPR, you could also state this in an advance decision to receive treatment (also known as a 'living will'), which would then be legally binding.

It’s possible in some circumstances that a doctor might issue a DNACPR order even if you or your family don’t agree with the decision. For example, if the doctor is convinced that the damage of CPR would outweigh any potential benefit. However, it’s more likely that they would take your preferences into account. Your healthcare team should also give you the opportunity to ask for a second opinion if you disagree with their decision.

If you haven’t stated a preference about CPR, your medical team is responsible for making a DNACPR decision. But they have a duty to discuss the decision with you. You can refuse CPR even if there is a chance that it may help you.

If you cannot make decisions for yourself, for example because you are unconscious or unable to communicate, the doctor should talk to your family or carers about your likely wishes. However, your family and/or next of kin don’t have an automatic right to decide which treatments you should or should not receive, unless you have given them the legal power to do so through a Lasting Power of Attorney for Health and Welfare.

What is cardiopulmonary resuscitation (CPR)?

 Cardiopulmonary resuscitation (CPR) involves physically attempting to restart your heart and/or breathing. It can involve:

  • chest compressions (repeatedly pushing firmly on the chest)
  • inflating the lungs (by inserting a tube into the windpipe or by placing a mask over the mouth and nose)
  • defibrillation (using electric shocks to correct the heart’s rhythm).

It can be distressing, especially for loved ones, and in some cases CPR can cause injuries such as punctured lungs, broken ribs and bruising. And patients who do survive it, may not regain consciousness, can suffer brain damage or may die soon afterwards, especially if they have multiple underlying conditions.

Overall, CPR can be successful in between 10%–20% of cases, but the success rate can drop to less than 2% for people with long-term conditions like cancer or other chronic illnesses.

Read more information from the NHS about the CPR process.

Why would a DNACPR decision be needed?

DNACPRs are designed to protect people from unnecessary suffering by receiving CPR that they don’t want, that won’t work, or where the harm outweighs the benefits.

In making the decision, a doctor must weigh up the risks and benefits of CPR for each individual. That includes:

  • Whether CPR is likely to be successful. Only around one in five CPR attempts in hospital are successful and even fewer outside a hospital.
  • Whether someone is coming close to the end of their life. In these circumstances CPR could be unwelcome and upsetting for the individual and their family.
  • Whether it will lead to poorer quality of life. For example, in some cases you can be left with permanent brain damage or in a coma. 

Are DNACPR forms legally binding?

Technically, a DNACPR form is not a legally binding document, but medical staff should abide by it once a form is in place. If you don’t want to be resuscitated and want this to be recorded in a legally binding document, you should make an advance decision to refuse treatment. For extra certainty, you should also ask for it to be recorded on a DNACPR form.

Telling others about your DNACPR form

Your DNACPR form needs to be available in an emergency so that any professionals caring for you know it exists.

  • If you’re in hospital, the form will be kept with your notes.
  • If you’re sent home, you should give a copy to your GP to keep with your records. 
  • You should also tell family members or carers about it and where it’s kept. This helps to avoid conflict between medical professionals and family members.

You can also ask for a DNACPR to be recorded in your emergency care plan (ECP), if you have one. ECPs are drawn up by medical professionals in discussion with you. They are designed to provide easily accessible, brief clinical recommendations for use in an emergency. They are usually put in place for people with complex health needs, life-limiting conditions or illnesses that can suddenly deteriorate or cause heart failure.

Improving the DNACPR decision process

Some problems have been identified with the use of DNACPR decisions, including misunderstandings, poor communication and inconsistent recording. These concerns were heightened during the Covid-19 pandemic, when many older, vulnerable or chronically ill people were separated from their families for long periods.

The Care Quality Commission (CQC) carried out a special review into these concerns, which found that during the pandemic some people were not given enough information or time to fully understand the DNACPR process. In some cases, people were not even aware that a DNACPR decision was in place. In its report, published in March 2021, the regulator also said it heard evidence that some healthcare providers had put ‘blanket’ DNACPR decisions in place. 

There should never be a blanket approach to DNACPR. People should always have the opportunity to discuss their wishes about care and treatment and decisions should be reached on an individual and compassionate basis.

Among its recommendations the CQC called for:

  • Better information and support for patients and their families and better training for healthcare staff.
  • A more consistent national approach to advance care planning. (DNACPR policies vary in different parts of the UK.)
  • Better monitoring and oversight of DNACPR decisions.

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