Dnacpr Form (Adult) Do Not Attempt Cardio-Respiratory Resuscitation (Dnacpr) Discussion Page 2
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3Date: ……/……/……/ Time: ...........................................
Signature: ........................................................................
In the event of a cardiac or respiratory arrest no attempts at cardio-respiratory resuscitation (CPR) will be made. All other
appropriate treatment and care will be provided.
The patient’s full name, date of birth and address must be written clearly with ballpoint pen or an addressograph
must be attached to each copy of the form.
The date of completing the form must be entered.
The decision must be communicated to all parties involved in the active care of the patient.
The patient’s clinical and DNACPR status should undergo routine review of circumstances. If reviewed please record
at top of the form.
1.
Capacity / Advance decisions
If the patient does not have capacity please ensure that an Assessment of Mental Capacity and Best Interests Decision form is
completed. Ensure that any Advance Decision is specific and valid and applicable to the patient’s current circumstances. Legal
advice can be considered in the event of disagreements, as recommended in the All Wales policy.
2.
Summary of main clinical problems and reasons why CPR would be inappropriate, likely to be unsuccessful or not
in the patient’s best interests.
Please be as specific as possible. More detailed information can be recorded in the patient’s healthcare record.
3.
Summary of communication with patient
State clearly what was discussed and agreed. If the decision was NOT discussed with the patient clearly state the reason why. If
an interpreter is used they must be approved by the organisation.
4.
Summary of discussion with those close to the patient (e.g. spouse/partner, family and trusted friends, carer, or
advocate)
If the patient does not have capacity those close to the patient must be consulted and may be able to help by indicating the
patient’s recent wishes. They cannot make the decision to withhold cardio-respiratory resuscitation - this is a medical decision. If
the patient has made a Lasting Power of Attorney for Health & Welfare, ensure that it is registered. If the patient has appointed a
Health & Welfare Attorney to make decisions on their behalf, that person must be consulted. A Health & Welfare Attorney may be
able to refuse life-sustaining treatment on behalf of the patient if this power is included in the original Lasting Power of Attorney.
If the patient has capacity - ensure that discussion with others is with their consent and does not breach confidentiality. State the
names and relationships of relatives or friends or other representatives with whom this decision has been discussed. More detailed
description of such discussion should be recorded in the clinical notes.
5.
Health professional completing this DNACPR form
This will vary according to circumstances and local arrangements. This should be a senior professional when available. The form
becomes active when a medical professional signs, times and dates the form and provides their GMC number.
The decision must be overseen by the senior responsible clinician (usually the patient’s Consultant or General Practitioner) at the
earliest opportunity. If the senior responsible clinician is NOT the doctor initially completing the form, they must be informed as
soon as reasonably possible. If a review of circumstances around the DNACPR form is necessary, this should be undertaken in
line with the all Wales policy. Any review of the decision is subject to communication requirements as outlined in All Wales
policy.
6.
Details of the senior responsible clinician involved in the decision
Ensure all details (name and position) are completed (see All Wales policy) and that the DNACPR decision is communicated to all
those involved in the patient’s care as in All Wales policy.
7.
Cancellation of the Decision
Ensure all details are completed. The form should be crossed through diagonally using 2 lines and “CANCELLED” should be
written clearly between them, and signed and dated by the doctor cancelling the decision. The cancelled form must be filed within
the current clinical record and this should be communicated to all copy holders below - as per All Wales policy.
COPIES of this DNACPR decision form have been sent to:
1.
Patient
2.
Primary Care/Out of Hours
3.
Other (please specify)/Out of Hours
4.
Audit
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