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Resuscitation and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy

1. Purpose

The purpose of this policy is to establish clear arrangements for cardiopulmonary resuscitation (CPR) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions within {{org_field_name}}.

{{org_field_name}} will ensure that its practice is consistent with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the Mental Capacity Act 2005 and its Code of Practice, the Human Rights Act 1998, the Equality Act 2010 and the current All Wales clinical policy, “Sharing and Involving – A clinical policy for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) for adults in Wales”.

The purpose of this policy is to ensure that:

• decisions about CPR are made on an individual basis and are not based on assumptions about age, disability, diagnosis, care-home residence or any other protected characteristic;
• the resident is involved in discussions and decision-making wherever this is possible and appropriate;
• mental capacity is assessed in accordance with the Mental Capacity Act 2005 where there is reason to doubt the resident’s capacity to participate in the relevant decision;
• valid and applicable Advance Decisions to Refuse Treatment are identified and respected;
• the legal authority of any Health and Welfare Attorney appointed under a registered Lasting Power of Attorney is identified and verified where relevant;
• DNACPR decisions are properly recorded, communicated, accessible and reviewed;
• DNACPR decisions relate only to CPR and do not mean that other appropriate treatment, nursing care, symptom control, comfort measures or palliative care will be withheld; and
• residents receive safe, dignified, person-centred care in accordance with their wishes, rights, personal plan and clinical needs.

2. Scope

This policy applies to all employees and other persons working at {{org_field_name}}, including registered nurses, care workers, healthcare assistants, managers, agency workers and other relevant staff.

It covers:

• assessment and communication relating to CPR;
• DNACPR decisions and the All Wales DNACPR form;
• Advance Decisions to Refuse Treatment, where these relate to CPR or other life-sustaining treatment;
• relevant Health and Welfare Lasting Powers of Attorney;
• advance and future care planning;
• mental capacity and best-interests decision-making;
• recording and communicating decisions within the resident’s personal plan and care records;
• responding to cardiac or respiratory arrest;
• transfer of residents between care settings;
• staff responsibilities and competency; and
• review of DNACPR arrangements when the resident’s clinical circumstances or wishes change.

A DNACPR decision relates specifically to whether CPR should be attempted following cardiac or respiratory arrest. It must not be interpreted as an instruction to withhold other clinically appropriate treatment, nursing care, symptom relief, hydration, nutrition, medication, hospital assessment or palliative and end-of-life care.

3. Related Policies

This policy should be read alongside:

• CHW38 – End of Life and Palliative Care Policy: Ensuring dignity in end-of-life care planning.
• CHW07 – Person-Centred Care Policy: Respecting individual preferences and choices.
• CHW39 – Mental Capacity and Deprivation of Liberty Safeguards Policy: Supporting legal compliance in decision-making.
• CHW36 – Communication and Engagement with Service Users and Families Policy: Ensuring open discussions with families regarding DNAR decisions.
• CHW11 – Safe Care and Treatment Policy: Maintaining appropriate clinical responses in emergencies.

4. Policy Statement

{{org_field_name}} is committed to ensuring that decisions concerning CPR and DNACPR are lawful, individualised, person-centred, clinically appropriate and respectful of each resident’s dignity, rights, wishes, feelings, beliefs and preferences.

No DNACPR decision will be made solely or automatically because a person:

• is of advanced age;
• has a disability;
• has dementia or another cognitive impairment;
• has a particular diagnosis;
• lives in a care home;
• requires significant care and support; or
• possesses any protected characteristic under the Equality Act 2010.

Decisions about CPR must be considered individually and, where clinically appropriate, as part of wider advance and future care planning.

Residents who have capacity must be appropriately involved in decisions concerning their treatment. Where a resident lacks capacity for the particular decision, the Mental Capacity Act 2005 must be followed.

A DNACPR decision is a clinical decision relating specifically to CPR. A DNACPR form is not, in itself, a legally binding refusal of treatment. This must be distinguished from a valid and applicable Advance Decision to Refuse Treatment concerning life-sustaining treatment, which has legal effect under the Mental Capacity Act 2005.

DNACPR does not mean “do not treat”. All other clinically appropriate care and treatment must continue to be considered and provided according to the resident’s needs, wishes, capacity and best interests.

4.1 Definitions

For the purposes of this policy:

• Cardiopulmonary Resuscitation (CPR) means emergency interventions intended to restore circulation and breathing following cardiac or respiratory arrest.
• Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) means a documented clinical decision that CPR should not be attempted if the resident experiences cardiac or respiratory arrest in the circumstances to which that decision applies. A DNACPR decision relates specifically to CPR and does not mean that other appropriate treatment or care should be withheld.
• All Wales DNACPR form means the nationally standardised documentation used in Wales to record a DNACPR clinical decision for an adult.
• Advance Decision to Refuse Treatment (ADRT) means a decision made by a person aged 18 or over, while they have capacity, to refuse specified treatment in specified circumstances at a future time when they may lack capacity. An ADRT refusing life-sustaining treatment must meet the additional statutory requirements in the Mental Capacity Act 2005 in order to be legally valid and applicable.
• Advance statement means a statement of a person’s wishes, feelings, beliefs and preferences concerning future care. It must be taken into account where relevant but does not have the same legal status as a valid and applicable ADRT.
• Lasting Power of Attorney for Health and Welfare means a legal arrangement under the Mental Capacity Act 2005 by which a person appoints one or more attorneys to make specified health and welfare decisions if that person subsequently lacks capacity. Authority concerning life-sustaining treatment exists only where the registered document gives the attorney that authority.
• Senior responsible clinician means the senior clinician responsible for overseeing the DNACPR decision in accordance with the current All Wales DNACPR policy.
• Representative means a person having legal authority, or the consent of the resident, to act on the resident’s behalf, consistent with the terminology used within the Welsh statutory guidance.

5. Decision-Making Process for CPR and DNACPR Decisions

Decisions concerning CPR and DNACPR must be made in accordance with the Mental Capacity Act 2005 and the current All Wales DNACPR clinical policy.

5.1 Individualised decision-making

Every decision must be made on an individual basis after considering the resident’s particular clinical circumstances, wishes and preferences.

DNACPR decisions must never be applied automatically to groups of residents or made solely because of age, disability, diagnosis, frailty, cognitive impairment or residence in a care home.

5.2 Residents who have mental capacity

A resident must be presumed to have capacity to make the relevant decision unless it is established otherwise.

Where the resident has capacity, they must be appropriately involved in decisions about their treatment and their views, wishes and preferences must be respected.

A resident with capacity may refuse treatment, including CPR. Where a resident wishes to make an advance refusal that will remain legally binding after loss of capacity, staff must facilitate access to an appropriate healthcare professional and, where necessary, independent advice regarding an Advance Decision to Refuse Treatment.

A DNACPR form must not be described to the resident as a legally binding “order”.

5.3 Mental capacity

Mental capacity is decision-specific and time-specific.

Where there is reason to doubt whether a resident has capacity to participate in the particular decision concerning CPR, an appropriate assessment must be undertaken and recorded in accordance with the Mental Capacity Act 2005.

A diagnosis of dementia, learning disability, mental illness or any other condition must not in itself be treated as evidence that a resident lacks capacity.

5.4 Residents who lack capacity

Where a resident lacks capacity for the relevant decision, healthcare professionals must act in accordance with the Mental Capacity Act 2005.

Those close to the resident, including family members, friends, carers or an advocate, should be consulted where appropriate to help establish the resident’s past and present wishes and feelings, beliefs, values and other factors that the resident would be likely to consider.

Family members must not be asked to make the DNACPR decision merely because they are the resident’s next of kin.

“Next of kin” status does not, by itself, confer legal decision-making authority.

5.5 Lasting Power of Attorney

Where a resident lacks capacity, staff must establish whether there is a registered Lasting Power of Attorney for Health and Welfare.

Where an attorney has been appointed, the documentation must be checked to establish:

• that the Lasting Power of Attorney is valid and registered; and
• whether the attorney has authority to make decisions concerning life-sustaining treatment.

Where the attorney has the relevant legal authority, they must be involved in accordance with the Mental Capacity Act 2005.

Where an attorney does not have authority concerning life-sustaining treatment, they should still be appropriately consulted as part of the best-interests process but must not be treated as having authority that the document does not provide.

5.6 Advance Decisions to Refuse Treatment

Where a resident has made an Advance Decision to Refuse Treatment which includes CPR or another form of life-sustaining treatment, the responsible healthcare professional must determine whether it is valid and applicable to the circumstances that have arisen.

A valid and applicable Advance Decision to Refuse Treatment relating to life-sustaining treatment has legal effect and must be respected.

An advance decision refusing life-sustaining treatment must satisfy the additional statutory requirements of the Mental Capacity Act 2005, including the applicable requirements relating to writing, signature, witnessing and the statement that the decision applies even if life is at risk.

If there is genuine uncertainty about the existence, validity or applicability of an Advance Decision to Refuse Treatment, urgent clinical and, where necessary, legal advice must be obtained.

The Mental Capacity Act permits life-sustaining treatment or action necessary to prevent a serious deterioration while a court determination concerning the validity or applicability of an apparent advance decision is being sought.

5.7 Responsibility for completing a DNACPR decision

The DNACPR decision must be made and documented by an appropriately authorised and competent registered healthcare professional in accordance with the current All Wales DNACPR policy and local clinical governance arrangements.

Where {{org_field_name}} authorises a registered nurse employed by the service to undertake DNACPR discussions and complete Section 5 of the All Wales DNACPR form, the provider must ensure that:

• the nurse meets the requirements of the current All Wales DNACPR Competency Framework;
• appropriate education and training has been completed;
• competency has been formally assessed and evidenced;
• suitable clinical governance arrangements are in place; and
• the decision is overseen by the senior responsible clinician in accordance with the All Wales policy.

Where a registered nurse employed by the care home completes Section 5, Section 6 should be completed by the senior responsible clinician as soon as practicable in accordance with current CIW expectations.

5.8 Review

DNACPR decisions must be reviewed when clinically indicated, including where:

• the resident’s clinical condition changes significantly;
• the resident’s wishes change;
• the circumstances on which the original decision was based have materially changed;
• there is uncertainty about whether the existing decision remains applicable; or
• review is requested or required under the applicable All Wales DNACPR arrangements.

Review must not become an automatic process that causes an otherwise appropriate decision to lapse solely because a predetermined period has elapsed.

6. Documentation and Record-Keeping

All decisions and discussions concerning CPR and DNACPR must be clearly, accurately and contemporaneously documented.

For adults, new DNACPR decisions must be recorded using the current All Wales DNACPR documentation in accordance with the current All Wales clinical policy.

The resident’s records and personal plan must clearly identify, where applicable:

• the existence and current status of a DNACPR decision;
• where the original DNACPR documentation is located;
• relevant discussions with the resident;
• the resident’s mental capacity in relation to the decision where this has been assessed;
• relevant discussions with family members, representatives, attorneys, advocates or others close to the resident;
• any Advance Decision to Refuse Treatment;
• any advance statement relevant to end-of-life care;
• any registered Health and Welfare Lasting Power of Attorney and the scope of the attorney’s authority;
• the name and professional status of the healthcare professional completing the DNACPR documentation;
• details of the senior responsible clinician where applicable;
• relevant review decisions; and
• communication of the decision to those responsible for the resident’s care.

The current DNACPR documentation must be readily accessible to staff in an emergency while remaining securely stored and protected from inappropriate access.

When a resident transfers between care settings, relevant DNACPR information must accompany or be communicated with the resident in accordance with the All Wales policy and applicable information-governance requirements.

Where a DNACPR decision is cancelled, the documentation must be clearly marked as cancelled in accordance with the All Wales process, retained within the clinical record as required, and the cancellation communicated promptly to all relevant persons and services holding or relying upon the previous decision.

Staff must not alter, create, cancel or sign clinical DNACPR documentation unless professionally authorised and competent to do so.

7. Staff Responsibilities and Training

All staff must understand their role in recognising and acting upon CPR, DNACPR, Advance Decisions to Refuse Treatment and relevant advance and future care planning information.

Care staff

Care staff must:

• know how to identify whether a resident has a recorded DNACPR decision;
• know where relevant emergency documentation is kept;
• follow the resident’s current DNACPR documentation, personal plan and emergency care instructions;
• understand that DNACPR applies only to CPR and does not authorise the withdrawal or withholding of other appropriate care or treatment;
• immediately seek appropriate emergency or clinical assistance where there is uncertainty about whether CPR should be commenced;
• provide appropriate comfort, dignity, reassurance and other required care to the resident;
• not create, alter, cancel or independently make a clinical DNACPR decision unless professionally authorised to do so; and
• report immediately any missing, contradictory, unclear or apparently outdated documentation to the registered nurse or manager and appropriate healthcare professional.

Registered nursing staff

Registered nursing staff must:

• ensure relevant DNACPR information is accurately reflected in the resident’s personal plan and care records;
• ensure that DNACPR documentation is readily accessible in an emergency;
• communicate relevant decisions to staff who need to know them;
• liaise with the GP, senior responsible clinician and other healthcare professionals when review or clarification is required;
• identify significant changes in the resident’s condition which may require clinical review of the DNACPR decision; and
• only undertake DNACPR discussions or complete clinical DNACPR documentation where they have the required professional authority, training, assessed competence and organisational governance arrangements.

Management

The Registered Manager must ensure that:

• staff understand this policy;
• staff know how to access the current All Wales DNACPR arrangements;
• sufficient appropriately trained and competent staff are available to respond to emergencies;
• DNACPR documentation and relevant care records are included within quality and record audits;
• any care-home nurse authorised to complete Section 5 of the All Wales DNACPR form has completed the required training and competency assessment and is supported by appropriate governance arrangements; and
• unsafe or unlawful blanket DNACPR decision-making is not accepted within the service.

Training

Training appropriate to each member of staff’s role must include:

• recognition of cardiac and respiratory arrest;
• the service’s emergency response arrangements;
• CPR appropriate to the member of staff’s role;
• understanding the meaning and limitations of DNACPR;
• awareness of Advance Decisions to Refuse Treatment;
• relevant Mental Capacity Act requirements;
• escalation where documentation is absent, unclear or disputed; and
• the distinction between DNACPR and withholding other treatment or care.

Training and competency must be refreshed at intervals appropriate to the staff member’s role and in response to changes in legislation, national guidance, policy or identified learning needs.

8. Communication, Resident Involvement and Involvement of Those Close to the Resident

Discussions concerning CPR and DNACPR must be undertaken sensitively, honestly and on an individual basis.

Where a resident has capacity, they must be appropriately involved in discussions about CPR and their wishes, preferences and decisions must be respected.

Information must be communicated in a way the resident can understand, taking account of communication needs, sensory impairment, cognition, language and any need for reasonable adjustments.

Where required, appropriate communication aids, interpretation, advocacy or other support must be arranged.

Where a resident with capacity wishes family members or others close to them to be involved, this should be facilitated with the resident’s consent.

Where the resident lacks capacity, those close to the resident should be consulted where appropriate to assist healthcare professionals in establishing the resident’s past and present wishes and feelings, beliefs, values and other matters the resident would be likely to consider.

Family members and persons described as “next of kin” do not automatically have authority to consent to or refuse CPR on behalf of an adult resident.

They must therefore not be asked to make the DNACPR decision unless they possess specific legal authority to make the relevant decision, for example under a valid and registered Health and Welfare Lasting Power of Attorney that includes authority concerning life-sustaining treatment.

Where no family member or appropriate person is available and the statutory criteria for appointment of an Independent Mental Capacity Advocate are met, an IMCA must be instructed in accordance with the Mental Capacity Act 2005.

Residents and those appropriately involved must be informed that a DNACPR decision applies only to CPR. It does not mean that other clinically appropriate treatment, nursing care, symptom management, palliative care, comfort or support will be withheld.

Any disagreement or concern concerning a DNACPR decision must be referred promptly to the relevant senior clinician. Where disagreement cannot be resolved, further senior clinical, safeguarding, advocacy or legal advice must be obtained as appropriate.

9. Emergency Situations and Implementation of CPR/DNACPR Decisions

In the event of an apparent cardiac or respiratory arrest, staff must immediately assess the situation and follow the resident’s current emergency care arrangements, the service’s emergency procedures and any relevant DNACPR or other legally applicable documentation.

Where a current DNACPR decision is in place

Staff must:

• follow the current DNACPR decision and the instructions recorded within the resident’s emergency care documentation;
• not commence CPR where the DNACPR decision applies to the circumstances of the arrest;
• immediately seek emergency clinical assistance where there is genuine uncertainty about the applicability of the decision;
• recognise that a DNACPR decision does not prevent the provision of other appropriate treatment, symptom relief, comfort measures or emergency care; and
• continue to preserve the resident’s dignity and provide appropriate care and support.

A DNACPR decision must not automatically prevent treatment of an unexpected and potentially reversible event where the circumstances fall outside those contemplated when the decision was made. Staff must follow the All Wales DNACPR policy and obtain urgent clinical or emergency-service advice where this issue arises.

Where a valid and applicable Advance Decision to Refuse Treatment exists

Where staff are aware of a valid and applicable Advance Decision to Refuse Treatment that refuses CPR in the circumstances that have arisen, this must be brought immediately to the attention of attending healthcare professionals and acted upon in accordance with the Mental Capacity Act 2005.

Where no DNACPR decision is known to be in place

Where a person has an unexpected cardiac or respiratory arrest and there is no known applicable DNACPR decision or Advance Decision to Refuse Treatment, staff trained and expected to provide CPR must commence the appropriate emergency response, summon emergency medical assistance immediately and follow the instructions of the emergency services, unless there are circumstances in which CPR should clearly not be attempted under applicable national clinical guidance.

Staff who are uncertain must seek immediate emergency clinical advice rather than making an unsupported decision not to provide CPR.

Following the event

The event, actions taken and relevant communications must be documented promptly in the resident’s records.

The Registered Manager or person in charge must ensure that any required notifications, incident reporting, safeguarding action or review is completed.

10. Legal, Regulatory and Professional Framework

This policy must be implemented in accordance with the following legislation, statutory guidance and national professional guidance, as amended or replaced:

• Regulation and Inspection of Social Care (Wales) Act 2016;
• Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, particularly the requirements concerning safe and appropriate care and support, personal plans, access to healthcare, staffing, staff competence, record keeping, policies and procedures and governance;
• Welsh Government statutory guidance for service providers and responsible individuals on meeting service standard regulations, as currently in force;
• Mental Capacity Act 2005 and Mental Capacity Act Code of Practice, including the statutory requirements relating to capacity, best interests, Lasting Powers of Attorney and Advance Decisions to Refuse Treatment;
• Human Rights Act 1998;
• Equality Act 2010;
• All Wales “Sharing and Involving – A clinical policy for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) for adults in Wales”, current version;
• All Wales DNACPR Competency Framework, where registered healthcare professionals employed by the service undertake DNACPR discussions or complete the relevant clinical documentation;
• current Resuscitation Council UK guidance; and
• relevant current professional guidance issued by the General Medical Council, Nursing and Midwifery Council and other applicable professional regulators.

The service will ensure that decisions about CPR are individualised, non-discriminatory and consistent with the resident’s rights.

A DNACPR clinical decision must always be distinguished from a valid and applicable Advance Decision to Refuse Treatment. A DNACPR form records a clinical decision concerning CPR; a valid and applicable Advance Decision to Refuse Treatment has legal effect under the Mental Capacity Act 2005.

11. Auditing and Compliance Monitoring

{{org_field_name}} will maintain effective arrangements to monitor compliance with this policy and the safety and quality of care provided to residents.

Auditing will include, where applicable:

• whether current DNACPR decisions are correctly identified within residents’ personal plans and records;
• whether DNACPR documentation is readily accessible in an emergency;
• whether Advance Decisions to Refuse Treatment and Health and Welfare Lasting Powers of Attorney are accurately recorded and distinguished from DNACPR decisions;
• whether mental capacity assessments and best-interests processes are appropriately documented where required;
• whether residents and those close to them have been involved appropriately;
• whether staff understand that family members or “next of kin” do not automatically have legal decision-making authority;
• whether DNACPR decisions have been communicated appropriately between relevant care and healthcare professionals;
• whether staff training and competency are appropriate to their roles;
• where care-home registered nurses are authorised to complete Section 5 of the All Wales DNACPR form, whether the required training, competency assessment, governance and senior responsible clinician oversight are evidenced; and
• whether any incident involving CPR, DNACPR or uncertainty about resuscitation has identified learning or required corrective action.

Any identified failure or risk must be acted upon promptly. Significant findings, themes and actions must be included within the service’s governance and quality-monitoring arrangements and escalated to the Responsible Individual where appropriate.

12. Policy Review

This policy will be reviewed at least annually and sooner where necessary following:

• a change in legislation or statutory guidance;
• an amendment to the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations;
• revised CIW requirements or guidance;
• revision of the All Wales DNACPR clinical policy or DNACPR documentation;
• revision of relevant Mental Capacity Act guidance;
• changes in recognised resuscitation guidance;
• a significant incident, complaint, safeguarding matter or audit finding relating to CPR or DNACPR; or
• identification of a change in practice that requires amendment of this policy.

Changes to this policy will be communicated to relevant staff, and training or competency assessment will be provided where the change affects staff responsibilities or practice.

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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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