• Anticipate the likelihood of cardiopulmonary arrest
• if CPR may be inappropriate, discuss DNACPR status with patient
• DNACPR order applies solely to cardiopulmonary resuscitation and does not affect any other aspect of treatment

Patient admitted with community DNACPR order

• Review DNACPR status as soon as is clinically possible
• Community DNACPR remains valid until a consultant review is completed

Clinical justification

• Prolonging a patient's life usually provides a health benefit to that patient
• A DNACPR order is ‘in the best interests of the patient' if one or more of the following applies:
• patient is irreversibly close to death
• despite successful CPR, there would be an unacceptably high probability of death or severe brain damage
• length and quality of life after resuscitation are unlikely to be valued by patient
• patient, who is mentally competent, has expressed consistent desire not to be resuscitated

Ethics and consent

• DNACPR is a clinical decision. It does require consent
• Complete Capacity assessment on ReSPECT form
  • if mentally competent, discuss DNACPR status with patient
  • if patient lacks capacity, discuss with others involved in the care and welfare of the patient if available
  • in an emergency, document but discuss ASAP

Documentation

• Document decision-making process at the time it happens on the ReSPECT form and in detail in the medical notes
• Once decision made, doctor (SpR or above) documents on the ReSPECT form document
• Once decision made, most senior nurse present must:
• write ‘not for cardiopulmonary resuscitation' prominently in nursing record
• sign entry and write name and post in capitals
• Senior doctor and nurse inform the ward team

Review

• Doctor reviewing the DNACPR order documents and dates the review on the ReSPECT document and in the medical record

DNACPR decision rescinded

• The decision must be written prominently in the medical notes by the doctor making the decision
• If the ReSPECT form is cancelled, cross through with two diagonal lines in black ball-point ink and the word 'CANCELLED' written clearly between them
  • date and print name and GMC/NMC number clearly underneath your signature to validate
• Senior nurse updates the nursing records and informs all other members of the healthcare team of the change in status

• If patient discharged from hospital with active DNACPR order, advise:
• the patient/carers to keep the document in a safe and visible place that carers, family and friends are aware of to ensure this is accessible in the event of an emergency
• the patient's GP is informed of the DNACPR via the discharge letter