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Registration Number: {{org_field_registration_no}}

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Resuscitation and DNAR (Do Not Attempt Resuscitation) Policy

1. Purpose

The purpose of this policy is to provide clear, lawful and person-centred guidance for the management of cardiopulmonary resuscitation (CPR) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) recommendations within {{org_field_name}}.

This policy is intended to ensure compliance with all applicable legislation and regulatory requirements in England, including:

• the Health and Social Care Act 2008;
• the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulations 9, 10, 11, 12, 13, 17 and 18 where applicable;
• the Mental Capacity Act 2005 and its Code of Practice;
• the Human Rights Act 1998;
• the Equality Act 2010; and
• applicable Care Quality Commission requirements and current national professional guidance concerning CPR and DNACPR decision-making.

{{org_field_name}} will also have regard to current guidance issued by the Resuscitation Council UK and other relevant national professional bodies.

A DNACPR recommendation is a clinical recommendation about whether CPR should be attempted if a person sustains a cardiac or respiratory arrest. It does not constitute a decision to withhold other treatment, care, symptom control, emergency assessment or hospital transfer.

A DNACPR recommendation must also be distinguished from a valid and applicable Advance Decision to Refuse Treatment (ADRT). An ADRT that lawfully refuses CPR or another form of life-sustaining treatment may be legally binding under the Mental Capacity Act 2005.

The purpose of this policy is to ensure that decisions and recommendations concerning CPR are individualised, clinically appropriate, non-discriminatory, properly communicated and recorded, and that the dignity, wishes, rights and legal protections of each person are respected.

2. Scope

This policy applies to:

• All employees, including care staff, nurses, and senior managers.
• General practitioners (GPs) and other healthcare professionals involved in care planning.
• People we support and their families, advocates, and legal representatives.
• External healthcare providers and emergency services liaising with {{org_field_name}} regarding resuscitation decisions.

3. Policy Statement

{{org_field_name}} is committed to ensuring that:

• Every decision or recommendation concerning CPR is made on an individual basis, having regard to the person’s clinical circumstances, wishes, preferences, rights and applicable legal requirements.
• No blanket DNACPR recommendation will be applied to people because they live in a care home or because they belong to a particular group.
• A DNACPR recommendation will not be made on discriminatory grounds, including because of age, disability, learning disability, autism, dementia, race, religion or belief, or another protected characteristic.
• Decisions will not be based upon a healthcare professional’s subjective assessment of a person’s quality of life.
• A person who has capacity to participate in discussions about CPR will be appropriately informed and involved in the decision-making process. A person does not have a right to demand clinically inappropriate treatment, including CPR where the responsible clinician considers that CPR would not be clinically effective.
• A person who lacks capacity to make a particular decision will continue to be involved and supported to participate as far as reasonably practicable. Any decision made on their behalf will comply with the Mental Capacity Act 2005.
• Relatives, friends and carers will not be treated as having legal decision-making authority merely because of their relationship with the person. They will be consulted where appropriate about the person’s wishes, feelings, beliefs and values as part of Mental Capacity Act decision-making.
• A person acting under a registered Health and Welfare Lasting Power of Attorney or a deputy appointed by the Court of Protection will only exercise decision-making powers that fall within the legal scope of their authority.
• Any valid and applicable Advance Decision to Refuse Treatment that applies to CPR will be respected in accordance with the Mental Capacity Act 2005.
• A DNACPR recommendation relates to CPR only. It must not result in the automatic withholding of other clinically appropriate care or treatment.
• CPR recommendations, ADRTs and relevant emergency care and treatment plans will be accurately recorded, accessible to staff who need the information to provide safe care, and handled securely and confidentially.
• Decisions about CPR will be reviewed at a frequency appropriate to the person’s individual circumstances and whenever there is a relevant change in clinical condition, circumstances or expressed wishes.
• Staff will receive training, support and competency assessment appropriate to their roles so that they understand how to respond safely to a cardiorespiratory arrest and how CPR and DNACPR recommendations operate.

4. Decision-Making Process

4.1 Person-Centred Approach

Every person must be treated as an individual and supported to participate as fully as possible in decisions and discussions about their care, including discussions concerning CPR.

Where the person has capacity to participate in the relevant decision, information must be provided in a way that they can understand and that meets their communication needs. Reasonable adjustments, interpretation, accessible information, advocacy or other appropriate support must be arranged where required.

Mental capacity must never be assumed to be absent merely because of a person’s age, diagnosis, disability, dementia, learning disability, autism, communication difficulty or because the person makes a decision that others consider unwise.

Where there is reason to doubt capacity, capacity must be considered in relation to the specific decision at the specific time and in accordance with the Mental Capacity Act 2005.

Where the person lacks capacity regarding the relevant decision, all practicable steps must be taken to enable and support their participation. The person’s past and present wishes and feelings, beliefs and values, and other factors they would be likely to consider must be taken into account.

Family members, friends, carers and advocates should be consulted where appropriate and practicable to help establish the person’s wishes, feelings, beliefs and values. They must not be treated as having authority to consent to or refuse treatment merely because they are the person’s relative or described as their next of kin.

Where a person has appointed an attorney under a registered Health and Welfare Lasting Power of Attorney, or where the Court of Protection has appointed a deputy with relevant authority, the scope of that person’s legal authority must be checked before relying upon any decision they make.

All discussions, assessments and significant decisions must be documented clearly in the person’s records.

4.2 Clinical Judgement and Legal Considerations

The clinical recommendation about whether CPR should be attempted is the responsibility of an appropriately qualified clinician acting within their professional competence and in accordance with applicable national and local clinical guidance.

A DNACPR recommendation must be based on an individual clinical assessment. It must not be applied automatically because of age, disability, diagnosis, residence in a care home or membership of any particular group.

Where CPR would not be clinically successful, or where the burdens and harms of CPR would outweigh its likely benefits, the responsible clinician may make a DNACPR recommendation. Consent from the person is not required for a clinician to decide not to offer treatment that is clinically inappropriate; however, the person has a right to be appropriately informed and involved in the decision-making process.

The person should normally be informed and consulted about a proposed DNACPR recommendation and the reasons for it. A decision not to discuss the matter with the person must not be made merely because the discussion may be upsetting or distressing. Where the responsible clinician considers that discussion would be likely to cause the person physical or psychological harm, the reason for not involving the person must be individually assessed and clearly documented.

Where the person lacks capacity concerning the relevant matter, the Mental Capacity Act 2005 must be followed. Appropriate people must be consulted where practicable in order to establish the person’s wishes, feelings, beliefs and values and to support lawful decision-making.

Where there is disagreement or uncertainty about a DNACPR recommendation, staff must promptly escalate the matter to the responsible clinician. The person or their lawful representative must be informed of available routes to seek review or a second clinical opinion where appropriate.

Where no DNACPR recommendation or other legally relevant record is available during an unexpected cardiorespiratory arrest, staff must immediately call 999, commence CPR where indicated and follow the instructions of the emergency call handler, unless there is clear and reliable information demonstrating that CPR should not be attempted, including a valid and applicable ADRT refusing CPR, or circumstances in which attempting CPR is clearly inappropriate.

4.3 Mental Capacity and Best Interests

Mental capacity must be assessed in accordance with the Mental Capacity Act 2005 whenever there is reason to doubt whether a person is able to make the particular decision in question.

Capacity is decision-specific and time-specific. A diagnosis of dementia, learning disability, autism, mental illness, neurological illness or any other condition does not by itself establish that the person lacks capacity.

Before concluding that a person lacks capacity, all practicable steps must be taken to support the person to understand, retain, use or weigh the relevant information and communicate their decision. Information and communication must be adapted to meet the person’s individual needs.

Where the person lacks capacity, decisions concerning treatment must be made in accordance with the Mental Capacity Act 2005 and the statutory best-interests requirements where those requirements apply.

A formal best-interests meeting is not required in every case. The nature and extent of consultation must be proportionate to the seriousness and complexity of the decision. For significant decisions involving life-sustaining treatment, appropriate consultation and clear documentation will normally be required.

The person making the relevant best-interests decision must, so far as reasonably practicable:

• encourage and support the person’s participation;
• consider the person’s past and present wishes and feelings;
• consider any written statement made by the person while they had capacity;
• consider the person’s beliefs and values;
• consider other factors that the person would be likely to consider;
• consult appropriate family members, friends, carers, attorneys, deputies or advocates where required or appropriate;
• consider whether the person is likely to regain capacity and whether the decision can safely wait; and
• ensure that any decision concerning life-sustaining treatment is not motivated by a desire to bring about the person’s death.

Relatives and next of kin do not automatically have authority to make healthcare decisions.

Where a Health and Welfare Lasting Power of Attorney exists, staff must verify that it is registered and determine the scope of the attorney’s authority. An attorney may only make a decision concerning life-sustaining treatment where the LPA expressly authorises the attorney to make such decisions.

Where there is no appropriate family member or friend to consult and the statutory requirements for an Independent Mental Capacity Advocate are met, an IMCA must be instructed in accordance with the Mental Capacity Act 2005.

Capacity assessments, consultations, decisions and the reasons supporting those decisions must be recorded clearly and contemporaneously.

4.4 Advance Decisions, Lasting Powers of Attorney and CPR

An Advance Decision to Refuse Treatment is different from a DNACPR recommendation.

A DNACPR recommendation is a clinical recommendation concerning CPR. It is not, by itself, a legally binding refusal of treatment.

A person aged 18 or over who has capacity may make an Advance Decision to Refuse Treatment specifying treatment that they wish to refuse if they later lack capacity to make that decision.

Where an ADRT purports to refuse CPR or another form of life-sustaining treatment, staff must immediately bring it to the attention of the responsible healthcare professional so that its validity and applicability can be established.

For an ADRT refusing life-sustaining treatment to satisfy the specific requirements of the Mental Capacity Act 2005, it must:

• be in writing;
• be signed by the person making it, or by another person at their direction and in their presence;
• have the signature witnessed;
• be signed by the witness; and
• include a clear statement that the decision is to apply even if life is at risk.

A valid and applicable ADRT refusing CPR has legal effect and must be respected.

If there is genuine uncertainty about the existence, validity or applicability of an ADRT during an emergency, staff must immediately call 999, explain the circumstances and follow emergency clinical advice while the matter is clarified. The Mental Capacity Act 2005 permits necessary life-sustaining treatment to be provided while a court decision is being sought where there is genuine doubt about the validity or applicability of an advance decision.

Where the person has a Health and Welfare Lasting Power of Attorney, staff must establish whether the LPA was made before or after any ADRT and whether the attorney has express authority concerning life-sustaining treatment. Any uncertainty must be referred promptly to an appropriate healthcare professional and, where necessary, for legal advice.

Copies or details of any known ADRT, Health and Welfare LPA, Court of Protection order or other relevant advance care planning document must be clearly recorded in the person’s care records and made available to healthcare professionals where required for the person’s care.

5. DNAR Documentation and Communication

5.1 Recording CPR and DNACPR Recommendations

All recommendations and decisions concerning CPR must be recorded accurately, clearly and contemporaneously.

Where a DNACPR recommendation is made, it must be recorded using the recognised documentation applicable to the person’s care, which may include a DNACPR form, ReSPECT plan or another locally approved emergency care and treatment plan.

The document must be completed and authorised by the appropriate clinician in accordance with applicable clinical and local requirements.

The care home must ensure that the person’s care record clearly identifies:

• whether there is a current recommendation concerning CPR;
• where the current original or recognised clinical document is located;
• the date on which the recommendation was made;
• any planned review arrangements;
• the identity of the responsible clinical team where known;
• whether the person has an ADRT;
• whether a registered Health and Welfare Lasting Power of Attorney is known to exist;
• whether any relevant Court of Protection order or deputyship exists; and
• any communication needs or reasonable adjustments required during emergency care.

Records must clearly distinguish between:

• a DNACPR or ReSPECT clinical recommendation;
• an ADRT;
• an advance statement of wishes and preferences;
• a Health and Welfare Lasting Power of Attorney; and
• a best-interests decision.

Staff must not treat these documents as legally interchangeable.

CPR and emergency care information must be readily available to staff who require it in order to provide safe care and to attending emergency healthcare professionals. Records must at the same time be stored and shared securely and confidentially in accordance with applicable information governance requirements.

Where the person transfers between care settings or travels away from the care home, relevant current emergency care documentation must accompany or be reliably communicated with the person in accordance with local health-system arrangements so that continuity and safety of care are maintained.

5.2 Reviewing CPR and DNACPR Recommendations

CPR and DNACPR recommendations must be reviewed at intervals appropriate to the person’s individual clinical circumstances.

A universal annual review interval must not be used as a substitute for individual clinical judgement.

The healthcare professional responsible for the person’s care should determine and record an appropriate review arrangement, including where appropriate a planned review date.

A review must be requested or arranged where appropriate when:

• there is a significant change in the person’s health or clinical condition;
• the circumstances on which the original recommendation was based have materially changed;
• the person’s expressed wishes or preferences change;
• the person or their lawful representative requests that the recommendation is reviewed;
• the person’s decision-making capacity relevant to the matter changes;
• there is uncertainty about whether the existing recommendation remains appropriate;
• the person moves permanently between care settings and review is clinically indicated; or
• a healthcare professional considers that review is required.

Care home staff must not independently cancel, amend or replace a clinician’s DNACPR recommendation. Where review is required, staff must contact the responsible GP, clinician or appropriate healthcare service promptly.

Any revised recommendation must be clearly communicated to relevant staff, obsolete documentation must be dealt with in accordance with local clinical procedures, and the person’s care record must be updated promptly.

5.3 Communicating CPR and DNACPR Recommendations

All staff who may be required to respond to an emergency involving a person must know how to establish whether there is a current CPR recommendation, emergency care plan or legally binding ADRT and where the relevant documentation is located.

Information concerning CPR must be communicated accurately during handovers, transfers and contacts with emergency healthcare professionals where it is relevant to the person’s care.

When emergency services attend, staff must promptly provide the current recognised DNACPR, ReSPECT, ADRT or other relevant emergency care documentation to the attending healthcare professionals.

Staff must understand that a DNACPR recommendation applies only to CPR. It does not mean:

• do not treat;
• do not call a doctor;
• do not call 999;
• do not admit to hospital;
• do not provide antibiotics;
• do not provide oxygen;
• do not treat choking or another potentially reversible emergency; or
• provide comfort care only.

Other clinically appropriate treatment, nursing care, personal care, symptom control, comfort measures and emergency assessment must continue unless there is a separate lawful decision or valid and applicable refusal relating to that particular treatment.

Where staff are uncertain about the meaning, validity, applicability or current status of a CPR-related document, they must seek immediate clinical advice rather than make assumptions.

6. Emergency Resuscitation Protocol

6.1 Responding to a Cardiorespiratory Arrest

Where a person is unresponsive and is not breathing normally, staff must immediately assess the situation, summon assistance and call 999 unless an emergency response has already been activated.

Where there is no clear and applicable instruction that CPR should not be attempted, CPR must be started promptly in accordance with the person’s circumstances and current resuscitation guidance.

Staff must:

• call 999 immediately;
• clearly state that the person is unresponsive and not breathing normally;
• provide the person’s location;
• tell the emergency call handler about any known DNACPR recommendation, ReSPECT plan, ADRT or other relevant emergency care document;
• commence CPR when indicated;
• use an available automated external defibrillator where appropriate and follow its instructions; and
• follow instructions given by the emergency call handler until emergency healthcare professionals take over or the person shows signs of life.

A member of staff must not delay CPR solely because they do not consider themselves sufficiently experienced or trained. They must call 999 immediately and follow the emergency call handler’s instructions.

Where there is a current DNACPR recommendation that applies to the circumstances, CPR should not ordinarily be commenced. Staff must nevertheless continue to provide all other appropriate care, including emergency assessment, treatment, symptom relief, comfort and dignity.

A DNACPR recommendation must not automatically prevent treatment of a reversible emergency.

Where a person with a DNACPR recommendation sustains a cardiorespiratory arrest as a result of an unexpected and potentially reversible cause that was not contemplated when the recommendation was made, including circumstances such as choking where appropriate, staff must immediately call 999, explain the circumstances and follow emergency clinical advice. A DNACPR recommendation must not be interpreted mechanically where there is reasonable doubt about whether it applies to the circumstances.

Where a valid and applicable ADRT specifically refuses CPR, it must be respected.

If there is uncertainty about whether an ADRT is valid or applicable, staff must immediately tell the 999 call handler or attending healthcare professionals and follow emergency clinical advice while the position is clarified.

Following any attempted resuscitation, unexpected cardiac arrest, emergency involving uncertainty about a DNACPR recommendation, or concern regarding the application of an ADRT, the Registered Manager or person in charge must ensure that the event is recorded, appropriately escalated and reviewed in accordance with the organisation’s incident reporting and governance procedures.

6.2 Staff Training and Competency

{{org_field_name}} will ensure that staff receive appropriate resuscitation training and updates relevant to their roles and responsibilities.

Staff whose roles may require them to respond to a cardiorespiratory arrest must receive CPR training at induction where required and regular updates thereafter. CPR training and competency must be maintained at least annually in accordance with current Resuscitation Council UK standards unless more frequent training is identified as necessary because of the person’s role, competency assessment or changes to national guidance.

Training must be appropriate to the staff member’s expected responsibilities and include, where applicable:

• recognition of cardiorespiratory arrest;
• summoning emergency assistance and calling 999;
• immediate CPR;
• use of an automated external defibrillator where available;
• following emergency call-handler instructions;
• the purpose and limitations of a DNACPR recommendation;
• the distinction between DNACPR, ReSPECT or other emergency care plans and a legally binding ADRT;
• the principles of the Mental Capacity Act 2005 relevant to CPR;
• appropriate involvement of people and those close to them;
• the prohibition of blanket or discriminatory DNACPR recommendations;
• recognition that DNACPR applies to CPR and does not mean that other treatment should be withheld;
• action to take where documentation is absent, unclear, disputed or potentially out of date; and
• procedures for communicating emergency care information to ambulance and other healthcare professionals.

Training records must be maintained.

Competence must be monitored and reassessed where necessary. Where an individual member of staff does not demonstrate the knowledge or practical skills required for their role, additional supervision, instruction or training must be provided before they undertake those duties without appropriate support.

All staff must know how to summon emergency assistance regardless of their individual level of CPR training.

7. Safeguarding, Equality and Ethical Considerations

Every CPR and DNACPR recommendation must be made on an individual basis.

Blanket DNACPR recommendations are prohibited. A recommendation must never be applied automatically because a person:

• lives in a care home;
• is older;
• is disabled;
• has dementia;
• has a learning disability;
• is autistic;
• has a particular diagnosis;
• belongs to a particular racial, religious or other group; or
• possesses any other protected characteristic.

A DNACPR recommendation must not be based on a healthcare professional’s subjective judgement that a person’s life is of lesser value or on discriminatory assumptions about the person’s quality of life.

Staff must raise a concern immediately where they have reason to believe that a DNACPR recommendation:

• has been applied on a blanket basis;
• may have been made unlawfully or discriminatorily;
• was made without appropriate individual clinical consideration;
• has been applied to the wrong person;
• may no longer be current or applicable;
• appears to conflict with a valid and applicable ADRT;
• has been imposed through coercion or undue pressure;
• has resulted, or may result, in other appropriate treatment being withheld; or
• was made without appropriate involvement or consultation required by law.

Immediate concerns about a person’s safety or treatment must be escalated to the person in charge, Registered Manager and appropriate healthcare professional. Safeguarding procedures must be followed where there is reasonable cause to suspect abuse, neglect, discriminatory abuse or improper treatment.

Where necessary, concerns must also be escalated to the relevant safeguarding authority, healthcare provider, commissioner, professional regulator or Care Quality Commission in accordance with the organisation’s safeguarding, whistleblowing and notification procedures.

Complaints concerning DNACPR recommendations or the care home’s management of CPR-related matters must be handled in accordance with the organisation’s complaints procedure and Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The Registered Manager must ensure that significant concerns, incidents and complaints relating to CPR or DNACPR are reviewed through the service’s governance arrangements so that risks are identified, appropriate action is taken and lessons are implemented.

8. Policy Review

This policy will be reviewed annually or earlier if:

• Legislation or CQC guidance changes.
• Significant concerns arise regarding DNAR decisions.
• Audit findings indicate a need for improvement.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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