Introduction
Few topics in medicine are as high-stakes, emotionally charged, and widely misunderstood as a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision. As a future FY1 doctor, you will be at the frontline of these conversations. This is why it is one of the most-tested topics in the UKMLA CPSA, assessing your professionalism, communication, and ethical judgment.
Handling this conversation poorly can cause immense distress to patients and families. Handling it well is a mark of a truly compassionate and competent doctor. This essential dnacpr decisions guide ukmla-ready framework provides a 5-step approach to help you navigate these complex discussions legally, ethically, and compassionately.
Key Takeaways
DNACPR is a medical decision about a single, specific medical treatment (CPR).
It is NOT “withdrawing all treatment.” The patient will still receive all other appropriate care, including antibiotics, fluids, and symptom control.
The ReSPECT form is the modern standard, replacing older, simpler DNACPR forms to allow for a more holistic plan.
Assessing mental capacity is a critical first step before any discussion.
This is a core CPSA test of your ability to handle UKMLA ethical dilemmas with professionalism.
Why This DNACPR Decisions Guide UKMLA is a Core Professional Skill
This is far more than just a form. It is a fundamental test of your medical professionalism.
Debunking the Myth: What DNACPR Is (and Is Not)
The biggest barrier to a good conversation is misunderstanding. You must be able to explain this clearly.
What it IS: A specific order not to attempt cardiopulmonary resuscitation (chest compressions, electric shocks, intubation) in the event the patient’s heart or breathing stops. This is because CPR is a traumatic, invasive procedure with a very low success rate in frail, elderly patients with multiple comorbidities.
What it is NOT: It is NOT a “Do Not Treat” order. It does NOT mean stopping antibiotics, IV fluids, food, oxygen, or any other comfort measure. You must state this explicitly: “This decision is only about CPR. All other active treatment for your condition will continue.”
The Legal & Ethical Framework
DNACPR decisions are a medical treatment decision, guided by clear ethical principles. The General Medical Council (GMC) provides explicit standards.
“You must be clear about the purpose of your conversation. You should aim to find out what matters to the patient… You must make good use of the patient’s clinical records, and any information about their wishes in other formats (for example… an advance decision to refuse treatment or a ReSPECT form).”
— GMC, Cardiopulmonary Resuscitation (CPR)
Why the CPSA Tests This Skill
Examiners are not trying to trick you. They are testing your fitness for safe practice. They want to see:
Professionalism: Can you handle a sensitive topic?
Ethics: Do you understand the principles of capacity, autonomy, and best interests?
Communication: Can you explain a complex idea (the futility of CPR) without using jargon and with empathy?
The 5-Step Framework for a DNACPR Discussion
This is your procedural framework for the CPSA station and for the ward.
Step 1: Prepare
Never walk into this conversation “cold.” Review the patient’s entire medical history.
What is their underlying diagnosis and prognosis?
Have they been deteriorating?
Is there an existing ReSPECT form, Advance Decision to Refuse Treatment (ADRT), or a Lasting Power of Attorney (LPA) for health and welfare?
Who is the patient’s next of kin?
Step 2: Assess Capacity
This is the first and most important step of the encounter. You must formally assess if the patient has the capacity to make this decision themselves.
If the patient HAS capacity, the discussion is with them.
If the patient LACKS capacity, you must hold a “Best Interests” discussion with their family or anyone named in an LPA.
For a full breakdown, you must review how to perform a mental capacity assessment.
Step 3: Set the Scene
This is a core communication skill.
Private: Find a quiet room or pull the bedside curtains.
People: Ensure the right people are there (the patient, key family members). Ask the patient who they want present.
Time: State the purpose clearly. “I’d like to talk to you about your health and your wishes for the future, especially if you were to get suddenly sicker.”
Physical: Sit down, make eye contact, and have tissues available.
Step 4: The Discussion (Explore Values)
Do not just “read a script.” This is a guided conversation.
Assess Understanding: “How do you feel your health has been recently?” “What’s your understanding of your illness?”
Explain CPR Realistically: Avoid the TV myth. Be honest and gentle. “If your heart were to stop, we can perform a procedure called CPR. This involves strong chest compressions and electric shocks. I have to be honest with you—in your situation, the chances of this working are very low, and it can cause a lot of harm, like broken ribs, without changing the final outcome.”
Explore Values: “What is most important to you right now?” “Have you thought about what you would or wouldn’t want in terms of medical treatment?”
Step 5: Make & Document the Recommendation (The ReSPECT Process)
Based on the patient’s wishes and your medical assessment, you make a joint recommendation. This is now formally documented on a ReSPECT form.
Recommendation: “Based on our conversation and your wishes for a peaceful, comfortable end of life, and my medical assessment that CPR would not be successful, I recommend we make a ‘Do Not Attempt CPR’ order. This will allow for a natural and dignified death if your heart stops. But I want to be clear: this does not mean we will stop treating your infection or managing your pain.”
Document: This is where the Resuscitation Council UK (ReSPECT) process is so important. You fill out the form, which documents this decision and all the other positive care goals (e.g., “For ward-based care,” “For symptom control”).
DNACPR vs. ReSPECT vs. ADRT: Understanding the Forms
These terms are often confused.
Table 1: Key Differences: DNACPR, ReSPECT, and ADRT
| Form | What It Is | Key Feature |
|---|---|---|
| DNACPR (Old) | A simple, ‘Do Not Resuscitate’ order. | Focuses only on the *negative* decision about CPR. Being phased out. |
| ReSPECT Form (New) | A holistic plan for emergency care. | Includes the DNACPR decision *plus* all the things you *will* do (e.g., “for ward-based care,” “for symptom control”). It is the new standard. |
| ADRT (Living Will) | A legally binding document written by a patient *with capacity* in advance. | Can be used to refuse *any* treatment, not just CPR. If valid and applicable, it is legally binding and you *must* follow it. |
The CPSA Script: What to Say (and What to Avoid)
This is a test of your communication. Your language must be clear, kind, and unambiguous.
What to Say: The 5-Step CPSA Script
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1. Set the Scene: “Hello Mrs. Smith, I’m Dr. [Name]. I’m one of the doctors looking after you. Is now an okay time to have a chat about your health and your thoughts for the future? Please let me know if you’d like anyone else here with you.”
2. Assess Understanding: “I know you’ve been in hospital for a few days with your chest infection. How are you feeling your health has been overall, in the last few months?”
3. Explain the “Why”: “As you know, your breathing condition (COPD) is very severe. We are doing everything we can to treat your infection. But I feel it’s important to be honest and plan for the future. I’m worried that if you were to get much sicker, some of the very invasive treatments we have might not be the best thing for you.”
4. Discuss CPR (Gently & Honestly): “One of those treatments is CPR. This is what you see on TV, with chest compressions and electric shocks. I must be honest with you: for someone with your severe lung condition, it is a very traumatic and physically damaging procedure that has an extremely low chance of success. It would likely not bring you back, and would instead lead to a painful and undignified death. My medical recommendation is that we do not attempt CPR, and instead focus all our energy on treating you with antibiotics, oxygen, and keeping you comfortable.”
5. Clarify & Confirm: “This is a ‘Do Not Attempt CPR’ recommendation. I want to be very clear: this does not mean we will stop doing anything else. We will continue to give you antibiotics, fluids, and all the treatment to make you better. This is only about not performing CPR if your heart was to stop. How do you feel about this?”
For more, the skills are very similar to those in our guide on breaking bad news.
Table 2: DNACPR Discussion Pitfalls (Dos & Don’ts)
| Pitfall | Why It’s a Problem (CPSA Fail) | What to Do Instead |
|---|---|---|
| ✗ Using Jargon | “Would you like us to ‘make you DNACPR’?” or “Do you want to be ‘for full resus’?” | ✓ Be clear. “I’d like to discuss what we should do if your heart or breathing were to stop.” |
| ✗ Offering CPR as a “Choice” | “Would you like us to do CPR?” This is wrong. CPR is a medical treatment that should not be “offered” if it is futile. | ✓ Make a recommendation. “My medical recommendation is that CPR would not be successful…” |
| ✗ Confusing DNACPR with “No Treatment” | “So we will just make you comfortable.” This is terrifying for a patient. | ✓ Be explicit. “I want to reassure you that we will continue to actively treat your infection with antibiotics and oxygen.” |
Putting It into Practice: 2 UKMLA-Style Clinical Scenarios
Scenario 1: The Patient with Capacity (End-Stage COPD)
Vignette: Mr. Jones, a 78-year-old with severe, oxygen-dependent COPD, is admitted with another infection. He is frail but has capacity. The consultant asks you to discuss his future care.
How to Handle: You use the 5-step framework.
Prepare: You know his prognosis is poor and he has had multiple ITU admissions.
Capacity: You confirm he understands his illness.
Scene: You sit with him and his wife.
Discussion: You explore his understanding. He says, “I don’t want to end up on one of those machines again.” This is your opening. You explain that CPR would be unsuccessful and painful.
Document: You agree on a ReSPECT form that states “Not for CPR” and “Not for ITU/ventilation,” but “For ward-based care” including IV antibiotics.
Scenario 2: The Patient Without Capacity (Best Interests Discussion)
Vignette: Mrs. Lee, an 88-year-old with severe dementia, is admitted from her nursing home with a severe stroke. She is unresponsive. Her daughter is present.
How to Handle:
Prepare: You identify the daughter is the Next of Kin (NOK).
Capacity: The patient clearly lacks capacity.
Scene: You take the daughter to the relatives’ room.
Discussion: This is a “Best Interests” meeting. You ask the daughter, “What would your mother have wanted?” “What did she value?” You explain that due to the severe stroke, CPR would have no chance of success and would only cause harm.
Document: You make a medical decision that DNACPR is in Mrs. Lee’s “best interests.” You document this conversation, stating that her daughter “understands and agrees” with the medical recommendation.
Your Turn: A Self-Assessment Exercise
Scenario: You are explaining to a patient’s son that you recommend a DNACPR order for his frail, 90-year-old mother. The son becomes upset and says, “What? So you’re just going to give up on her? I want you to do everything!”
Your Task: Write the first 1-2 sentences of your empathetic yet clear response.
Model Answer: “I can absolutely see how upsetting this is, and I want to reassure you we are not giving up on your mother. This decision is only about CPR, a specific procedure that I believe would not work and would only cause her harm.” “The most important thing I want to make clear is that ‘Do Not Attempt CPR’ does not mean ‘Do Not Treat.’ We will continue to give her antibiotics, fluids, and all other care to keep her comfortable and treat her infection.”
Frequently Asked Questions (FAQ) about dnacpr decisions guide ukmla
This is a key part of our dnacpr decisions guide ukmla. A DNACPR decision is a medical decision made by a senior clinician, based on a “best interests” framework. CPR is a medical treatment, and like any treatment, it should not be given if it is futile (i.e., will not work). However, the patient’s known wishes are the most important factor in that “best interests” decision. If a patient with capacity refuses CPR, you must respect that refusal.
No. A family or patient can refuse treatment, but they cannot demand a specific treatment that the clinical team believes is futile or will cause harm. In this difficult situation, your job is not to argue, but to explain why it is futile with compassion. Use phrases like, “I understand you want us to do everything. The reason for my recommendation is that I believe CPR would be physically harmful and would not succeed in bringing her back. Instead, I want to focus our efforts on treatments that will help, like managing her pain and keeping her comfortable.”
No. This is the single most important myth to bust. DNACPR does not mean do not treat. It means “Do Not Attempt Cardiopulmonary Resuscitation.” The patient will and must continue to receive all other appropriate medical care, including oxygen, antibiotics, IV fluids, pain relief, and nursing care. You must state this explicitly.
If a patient lacks capacity and has no family, an Independent Mental Capacity Advocate (IMCA) may need to be involved in the best interests decision. The decision is still made by the senior medical team, led by the consultant, based on what is in the patient’s best interests.
This is a related, but separate, decision. “Escalation” refers to the “ceiling of care.”
For Escalation: Means the patient is for all treatment, including admission to the Intensive Care Unit (ICU) for ventilation, if needed.
Not for Escalation: Means the patient will receive “ward-based care” (e.g., IV antibiotics, oxygen) but is not a candidate for ICU or ventilation. A patient can be “Not for Escalation” but still be “For CPR” (a rare, but possible, scenario). These decisions are all documented on the ReSPECT form.
You should have a “future care” or “ceiling of care” discussion with any patient who is at high risk of deteriorating or who has a life-limiting illness (e.g., severe COPD, metastatic cancer, end-stage heart failure). This is good, proactive medical care and is increasingly documented on the ReSPECT form.
A valid and applicable Advance Decision to Refuse Treatment (ADRT) is legally binding. If a patient with capacity has previously written a valid ADRT stating they refuse CPR, you must respect it. It has the same legal weight as a real-time refusal from a patient with capacity.
A DNACPR form is an old, simple document that only states one thing: “Do not attempt CPR.” A ReSPECT form is a much more holistic, patient-centred document that includes the DNACPR decision but also documents all the positive care decisions, such as “For ward-based care,” “For symptom control,” “Prefer to be cared for at home,” etc. ReSPECT is the new standard.
You must be respectful and sensitive. Ask questions to understand their values. For example: “I understand that your faith is very important to you. To help me make the best recommendations, could you tell me what your faith says about situations like this, or what is most important to you?” You can (and should) involve the hospital chaplaincy or a relevant religious leader if the patient/family agrees.
No. An FY1 doctor should not be making the final DNACPR decision alone. This decision must be made by a senior doctor (ST4+/Registrar or Consultant). Your role as an FY1 is to identify patients who need the discussion, initiate the conversation (if you feel confident), and document the discussion clearly. The final form must be signed by a senior.
Conclusion
Navigating DNACPR decisions is one of the most challenging and important responsibilities you will have. It is a core test of your ability to combine medical knowledge, ethical principles, and compassionate communication. Remember that you are not “giving up” on a patient; you are advocating for a good, dignified death by preventing a futile and traumatic procedure.
By using this 5-step framework, you can approach these conversations not with fear, but with the confidence that you are following best practice. This skill is central to your role as a professional and is a key part of the broader, vital skills of palliative care.
Your Next Steps
Read the official guidance: Review the GMC’s CPR guidance and the ReSPECT form itself.
Shadow a senior: Ask your registrar or consultant if you can sit in on a DNACPR/ReSPECT discussion. It’s the best way to learn.
Practice the script: Role-play the “What to Say” script with a colleague. Practice saying the difficult words “CPR,” “die,” and “not successful” in a clear and empathetic way.
