DC129-Resuscitation, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), ReSPECT and Advance Care Planning Policy

Registration Number: {{org_field_registration_no}}

Resuscitation, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), ReSPECT and Advance Care Planning Policy

1. Purpose

The purpose of this policy is to provide a clear, consistent, person-centred and legally compliant framework for responding to resuscitation, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), ReSPECT, Advance Decision to Refuse Treatment (ADRT), and emergency care planning decisions within {{org_field_name}}.

This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Care Quality Commission (CQC) Fundamental Standards, the Mental Capacity Act 2005, the Human Rights Act 1998, the Equality Act 2010, UK GDPR and the Data Protection Act 2018, and current Resuscitation Council UK guidance.

The aim of this policy is to ensure that service users’ rights, wishes, dignity, equality, safety, consent and best interests are respected at all times. It also ensures that staff understand what they must do in an emergency, how to recognise and act on valid DNACPR, ReSPECT or ADRT documentation, when to call emergency services, how to escalate concerns, and how to record and report actions taken.

2. Scope

This policy applies to all employees, care workers, senior care workers, agency staff, volunteers, office staff, supervisors, coordinators, nominated individual, registered manager and any other person working for or on behalf of {{org_field_name}} in the delivery of domiciliary care services.

This policy applies to all service users receiving care and support from {{org_field_name}}, including people who have capacity to make decisions about CPR and emergency treatment, people who may lack capacity for specific decisions, people with a valid ADRT, people with a DNACPR decision, and people with a ReSPECT or treatment escalation plan.

This policy covers:

the meaning of CPR, DNACPR, ReSPECT, treatment escalation plans and ADRTs;
the legal and ethical principles that apply to resuscitation decisions;
the role and limitations of domiciliary care staff;
emergency action where a DNACPR decision is present, absent, unclear, disputed or unavailable;
communication with service users, families, representatives, advocates, GPs, district nurses, paramedics and other healthcare professionals;
mental capacity, consent, best interests and lawful representatives;
record keeping, confidentiality, information sharing and document storage;
CQC notifications, incident reporting, safeguarding and duty of candour;
staff training, supervision, competency and governance arrangements.

3. Legal and Regulatory Framework

This policy must be read alongside the following legislation, regulations, guidance and professional standards:

Health and Social Care Act 2008 – establishes the CQC and the regulatory framework for health and adult social care in England. The CQC’s objective includes protecting and promoting the health, safety and welfare of people who use health and social care services.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – including, where relevant, Regulation 9 Person-centred care, Regulation 10 Dignity and respect, Regulation 11 Need for consent, Regulation 12 Safe care and treatment, Regulation 13 Safeguarding service users from abuse and improper treatment, Regulation 16 Receiving and acting on complaints, Regulation 17 Good governance, Regulation 18 Staffing, Regulation 19 Fit and proper persons employed and Regulation 20 Duty of candour.
Care Quality Commission (Registration) Regulations 2009 – including Regulation 16 Notification of death of a service user and Regulation 18 Notification of other incidents.
Mental Capacity Act 2005 and Mental Capacity Act Code of Practice – including the presumption of capacity, support to make decisions, the right to make unwise decisions, best interests decision-making, and the least restrictive option.
Human Rights Act 1998 – including the right to life, the right to respect for private and family life, and protection from inhuman or degrading treatment.
Equality Act 2010 – DNACPR decisions must never be made on a blanket basis or because of age, disability, diagnosis, learning disability, autism, frailty or any other protected characteristic.
UK GDPR and Data Protection Act 2018 – DNACPR, ReSPECT, ADRT and emergency care records are confidential health and care information and must be processed lawfully, securely and only shared on a need-to-know basis.
Resuscitation Council UK guidance on CPR, DNACPR and ReSPECT – including current guidance on decisions relating to cardiopulmonary resuscitation and emergency care planning.
Oliver McGowan Code of Practice on statutory learning disability and autism training – staff must receive learning disability and autism training appropriate to their role.
Local Integrated Care Board, NHS, ambulance service and local authority procedures where these apply to DNACPR, ReSPECT, advance care planning, safeguarding or end-of-life care.

4. Understanding CPR, DNACPR, ReSPECT and Advance Decisions

Cardiopulmonary Resuscitation (CPR): CPR is an emergency intervention used when a person has a cardiac or respiratory arrest. CPR may include chest compressions, rescue breaths, defibrillation and other emergency clinical interventions by healthcare professionals or emergency responders.

DNACPR: DNACPR means Do Not Attempt Cardiopulmonary Resuscitation. A DNACPR decision means that CPR should not be attempted if the person has a cardiac or respiratory arrest. It does not mean “do not treat”, “do not care”, “do not call a doctor”, “do not call 999”, or “do not provide comfort, symptom relief or other appropriate care”.

DNAR: DNAR is an older or alternative term sometimes used to mean the same as DNACPR. Within this policy, DNACPR is used for consistency.

ReSPECT: ReSPECT means Recommended Summary Plan for Emergency Care and Treatment. A ReSPECT plan records personalised recommendations for a person’s clinical care and treatment in a future emergency where they may be unable to make or express choices. A ReSPECT form may include a recommendation about CPR, but it is wider than CPR and may include other emergency care preferences.

Treatment Escalation Plan (TEP): A Treatment Escalation Plan records clinical decisions about what treatments should or should not be considered if a person deteriorates. Staff must follow the same principles of checking validity, recording, communication and escalation.

Advance Decision to Refuse Treatment (ADRT): An ADRT is a legally binding decision made by a person aged 18 or over, while they had capacity, to refuse specified treatment in specified circumstances. An ADRT refusing life-sustaining treatment, including CPR, must be in writing, signed, witnessed, and must include a statement that it applies even if life is at risk.

Advance Statement: An advance statement records a person’s wishes, feelings, values and preferences. It is not legally binding in the same way as a valid and applicable ADRT, but it must be considered when planning care and making best interests decisions.

Important principle: A DNACPR decision applies only to CPR. Staff must continue to provide all other appropriate care and support within their role, including comfort, reassurance, dignity, basic first aid where appropriate, calling for clinical advice or emergency assistance, and supporting family members or representatives.

4.1 Prohibition of Blanket DNACPR Decisions

DNACPR decisions must be made on an individual basis. {{org_field_name}} will not accept, apply, encourage or tolerate blanket DNACPR decisions for any group of service users.

A DNACPR decision must never be made because of a person’s age, disability, diagnosis, learning disability, autism, frailty, care setting, infection status, apparent quality of life, or any other protected characteristic.

Where staff become aware of a DNACPR decision that appears to have been made on a blanket, discriminatory or unclear basis, they must report this immediately to the registered manager or senior person on duty. The registered manager must escalate the concern to the GP, responsible clinician, community nursing team, safeguarding team, advocate or emergency services as appropriate.

Any concern that a service user’s rights, wishes, dignity, equality or safety have not been respected must be recorded, investigated and acted on under the organisation’s safeguarding, complaints, mental capacity and incident reporting procedures.

5. Making, Recording, Checking and Reviewing DNACPR, ReSPECT and ADRT

DNACPR decisions are clinical decisions and must be made by an appropriately qualified healthcare professional, such as the person’s GP, hospital consultant, specialist nurse or other clinician acting within their professional scope and local procedures. Domiciliary care staff must not make DNACPR decisions unless they are appropriately qualified and authorised to do so within their professional role.

Wherever practicable and appropriate, the service user must be involved in discussions about CPR, DNACPR, ReSPECT and emergency care planning. Discussions must be handled sensitively, in a way the person can understand, and with appropriate support, advocacy or communication aids where required.

Where the service user has capacity to make the relevant decision, their decision must be respected, including the right to refuse CPR through a valid and applicable ADRT.

Where the service user lacks capacity to participate in or make the relevant decision, any decision must be made in accordance with the Mental Capacity Act 2005. The decision-maker must consider the person’s past and present wishes, feelings, beliefs and values, and consult those who are appropriate and practicable to consult, such as family members, friends, attorneys, deputies, advocates and professionals involved in the person’s care.

Where a person has a valid and applicable Lasting Power of Attorney for Health and Welfare, or a Court of Protection appointed deputy with authority to make decisions about life-sustaining treatment, this must be taken into account. Staff must seek clarification from the registered manager and relevant healthcare professional if there is any uncertainty.

A DNACPR, ReSPECT, TEP or ADRT document must be:

clearly identifiable;
legible;
attributable to the person;
signed or authorised in line with local requirements;
current and applicable to the circumstances;
stored where staff and emergency responders can access it promptly;
referenced in the service user’s care plan and risk assessment;
communicated to relevant staff on a need-to-know basis;
reviewed when the person’s condition, wishes, care setting or circumstances change.

The original or recognised current document should be kept in the service user’s home in an agreed and accessible location, normally the care folder, unless local NHS or ambulance service arrangements specify otherwise. Electronic care planning systems must clearly flag the presence of DNACPR, ReSPECT, TEP or ADRT documentation, but staff must still know where the original or current document can be found.

Staff must not alter, complete, sign, amend or remove DNACPR, ReSPECT, TEP or ADRT forms. Any apparent error, uncertainty, missing signature, inconsistency, expiry, dispute or concern must be escalated immediately to the registered manager and relevant healthcare professional.

5.1 Mental Capacity, Consent and Best Interests

Staff must assume that a service user has capacity to make decisions unless it is established that they lack capacity for the specific decision at the specific time. A person must not be treated as unable to make a decision merely because they make a decision that others consider unwise.

Staff must support service users to understand, retain, use or weigh relevant information and communicate their decision, using accessible information, interpreters, communication aids, family support or advocacy where appropriate.

If a service user lacks capacity for a decision about CPR or emergency treatment, the decision must be made in their best interests by the appropriate decision-maker, usually the responsible clinician. Care staff must contribute relevant information where appropriate, including the person’s known wishes, preferences, beliefs, values and day-to-day presentation.

Where there is no family member, friend, attorney or deputy appropriate to consult, and the decision is serious medical treatment, the responsible healthcare professional may need to involve an Independent Mental Capacity Advocate (IMCA). Staff must escalate any concerns about lack of representation to the registered manager.

Any concern about capacity, consent, coercion, pressure from others, conflict between family members, or disagreement about a DNACPR, ReSPECT or ADRT decision must be escalated immediately and recorded.

5.2 Advance Decisions to Refuse Treatment (ADRT)

Where a service user has an ADRT refusing CPR or other life-sustaining treatment, staff must check that the ADRT appears to be valid and applicable to the current circumstances. Staff must not ignore a valid and applicable ADRT.

An ADRT refusing life-sustaining treatment must be in writing, signed by the service user or signed by another person in the service user’s presence and at their direction, witnessed, and must include a clear statement that the decision applies even if life is at risk.

Staff must immediately escalate to the registered manager and relevant healthcare professional if:

the ADRT cannot be found;
the ADRT is unclear, incomplete or illegible;
the ADRT does not appear to apply to the current circumstances;
there is evidence the person has withdrawn or changed the decision;
there is disagreement about whether the ADRT is valid or applicable;
the service user’s current wishes appear inconsistent with the ADRT.

Where there is genuine uncertainty in an emergency, staff must call 999 and follow the emergency procedure in this policy.

6. Role of Care Workers in DNACPR and Emergency Situations

Care workers must act promptly, calmly and within their training, competence and role. Staff must follow the service user’s care plan, emergency plan and any valid and applicable DNACPR, ReSPECT, TEP or ADRT documentation that is available.

Where the service user has a valid and applicable DNACPR decision:

staff must not commence CPR if the service user has a cardiac or respiratory arrest;
staff must still provide comfort, reassurance, privacy, dignity and compassionate support;
staff must call 999 where required by the care plan, local procedure, the circumstances of the emergency, uncertainty about death, safeguarding concerns, family distress, or where clinical advice or attendance is needed;
staff must inform ambulance personnel or other attending healthcare professionals that a DNACPR, ReSPECT, TEP or ADRT document exists and show them the document where available;
staff must remain with the service user where safe to do so and follow the instructions of emergency services or healthcare professionals;
staff must contact the office, on-call manager or registered manager as soon as practicable;
staff must record the event accurately, including the time, observations, who was contacted, advice received, action taken and where the DNACPR/ReSPECT/ADRT document was located.

Where there is no DNACPR, ReSPECT, TEP or ADRT document available:

staff must call 999 immediately if the person is unresponsive and not breathing normally or there is any serious concern;
staff trained in basic life support must commence CPR where it is safe and practicable to do so, following their training and emergency services instructions;
if staff are not trained or cannot safely provide CPR, they must follow the instructions of the emergency call handler and provide any support they safely can;
staff must continue until emergency services arrive, the person shows signs of life, staff are physically unable to continue, or the emergency call handler or attending clinician advises otherwise.

Where a DNACPR, ReSPECT, TEP or ADRT document is unclear, missing, not available, disputed or appears invalid:

staff must call 999 immediately;
staff must explain the uncertainty to the call handler;
staff must follow the emergency call handler’s instructions;
staff must inform the office, on-call manager or registered manager as soon as practicable;
staff must record the uncertainty, advice received and actions taken.

Where the service user is deteriorating but has not had a cardiac or respiratory arrest:

DNACPR does not prevent assessment, treatment or escalation;
staff must seek medical advice, call 111, contact the GP, district nursing team, palliative care team or call 999 depending on the urgency and care plan;
staff must continue to provide care and support within their role and training.

7. Communication, Involvement and Respect for Service User Wishes

Service users must be supported to express their wishes, feelings, values and preferences about resuscitation, emergency care and end-of-life care where they wish to do so. Staff must not pressure service users into making decisions and must not raise DNACPR discussions outside their role, training or competence.

Where a service user wishes to discuss CPR, DNACPR, ReSPECT, ADRT or emergency care planning, staff must listen respectfully and refer the person to the registered manager, GP, community nurse, palliative care team or other appropriate healthcare professional.

Communication must be person-centred and accessible. Staff must consider communication needs, sensory needs, language, culture, religion, disability, learning disability, autism, mental health, dementia, advocacy needs and the involvement of people important to the service user.

Staff must respect confidentiality. Information about DNACPR, ReSPECT, TEP or ADRT decisions must only be shared with staff and professionals who need the information to provide safe and lawful care, or where sharing is otherwise legally required or justified.

Families, friends or representatives may be involved where the service user consents, where they have legal authority, or where involvement is appropriate under the Mental Capacity Act 2005. Family members cannot demand or refuse CPR on behalf of a person unless they have the relevant legal authority.

Any disagreement, distress, complaint or challenge about a DNACPR, ReSPECT, TEP or ADRT decision must be escalated to the registered manager and relevant healthcare professional. Staff must not attempt to resolve clinical disputes themselves.

7.1 Record Keeping and Document Control

The care plan must clearly record whether the service user has a DNACPR decision, ReSPECT plan, TEP, ADRT, advance statement or other emergency care plan, and where the current document is kept.

Records must include:

the type of document;
the date of the document;
the person or organisation that completed or issued it;
where the original or current version is stored;
whether staff have been informed;
any review date, if known;
any concerns, disputes or actions required.

Staff must check the care plan at the start of care and must report immediately if a DNACPR, ReSPECT, TEP or ADRT document is missing, damaged, illegible, inconsistent with the care plan, or appears out of date.

Records must be factual, accurate, timely, signed or attributable to the person making the entry, and stored securely. Records must not include personal opinions, assumptions or discriminatory language.

DNACPR, ReSPECT, TEP and ADRT information must be handled as confidential health and care information under UK GDPR and the Data Protection Act 2018.

7.2 Equality, Human Rights and Safeguarding

{{org_field_name}} will protect service users from discrimination, abuse, neglect, coercion and improper treatment in relation to CPR, DNACPR, ReSPECT, TEP and ADRT decisions.

Staff must report immediately if they believe:

a DNACPR decision has been made without proper individual consideration;
a decision has been made because of age, disability, diagnosis, frailty, learning disability, autism or care setting;
the service user was not involved when they should have been;
the person lacked capacity and there is no evidence of a best interests process;
a family member, professional or other person is placing pressure on the service user;
a document appears falsified, altered or completed incorrectly;
the person’s wishes are being ignored;
there is any risk of abuse, neglect or breach of human rights.

Concerns must be escalated under the safeguarding procedure and to relevant healthcare professionals. Where there is immediate risk, staff must call 999.

8. Training, Competency and Staff Responsibilities

All staff must receive training appropriate to their role before working with service users where CPR, DNACPR, ReSPECT, TEP, ADRT or end-of-life care may be relevant.

Training must include, as appropriate to role:

basic life support and emergency response;
how to recognise cardiac or respiratory arrest;
when and how to call 999;
the meaning and limits of DNACPR decisions;
ReSPECT and treatment escalation planning;
ADRTs and advance statements;
Mental Capacity Act 2005 principles, consent, best interests and advocacy;
equality, human rights and avoiding discriminatory or blanket decisions;
end-of-life care, dignity, comfort and emotional support;
communication with service users, families, advocates and professionals;
record keeping, confidentiality and information sharing;
incident reporting, safeguarding, duty of candour and CQC notifications;
local procedures for locating and checking DNACPR, ReSPECT, TEP and ADRT documentation;
Oliver McGowan learning disability and autism training appropriate to the staff member’s role.

Staff must not act outside their training, competence or role. Where staff are unsure, they must seek advice from the office, on-call manager, registered manager, GP, district nurse, palliative care team, 111 or 999 depending on the urgency.

Refresher training must be completed at intervals set by {{org_field_name}}, and at least annually for emergency response and this policy, or sooner where there is a change in legislation, guidance, local procedure, role, risk, incident learning or staff competency need.

The registered manager is responsible for ensuring staff are trained, supervised and competent, and that training records are maintained.

9. Governance, Audit and Compliance Monitoring

{{org_field_name}} will monitor compliance with this policy through effective governance systems in line with CQC Regulation 17 Good governance.

Monitoring will include:

audits of care plans where DNACPR, ReSPECT, TEP, ADRT or end-of-life care is relevant;
checks that documents are current, accessible and correctly referenced in care records;
review of emergency incidents, deaths, near misses, safeguarding concerns, complaints and compliments;
review of staff knowledge during supervision, spot checks, competency assessments and team meetings;
checks that staff training is completed and up to date;
review of communication with GPs, district nurses, palliative care teams, ambulance services and families or representatives;
confirmation that CQC notifications have been made where required;
review of duty of candour requirements where a notifiable safety incident may have occurred;
action planning and learning following incidents, concerns or changes in guidance.

The registered manager is responsible for ensuring that any DNACPR-related incident, concern, complaint or safeguarding issue is investigated, recorded, escalated and learned from.

Where audit or incident review identifies a shortfall, {{org_field_name}} will take prompt action, which may include updating the care plan, contacting healthcare professionals, providing staff supervision, retraining staff, making safeguarding referrals, notifying CQC, or reviewing this policy.

9.1 CQC Notifications, Incident Reporting and Duty of Candour

The registered manager must consider whether a statutory notification to CQC is required following any death, serious injury, safeguarding concern, allegation of abuse, event that affects the safe running of the service, or other notifiable incident connected with CPR, DNACPR, ReSPECT, TEP, ADRT or emergency care.

Deaths of service users must be notified to CQC where required under Regulation 16 of the Care Quality Commission (Registration) Regulations 2009. Other incidents must be notified where required under Regulation 18.

Staff must report all incidents, near misses, concerns, disputes or documentation problems immediately to the registered manager or senior person on duty.

Where a notifiable safety incident has occurred, {{org_field_name}} will comply with the duty of candour. This means acting in an open and transparent way, informing the relevant person, providing reasonable support, giving a truthful account of what is known, apologising where appropriate, and keeping a written record of the process.

Any incident involving possible discrimination, blanket DNACPR decision-making, failure to follow a valid ADRT, missing documentation, failure to call emergency services when required, or failure to provide appropriate care must be treated as a serious governance concern and investigated.

9.2 Working with Healthcare Professionals and Emergency Services

{{org_field_name}} recognises that responsibility for making DNACPR and emergency treatment decisions usually rests with healthcare professionals, not domiciliary care providers. However, domiciliary care staff have an important role in recognising documentation, communicating information, escalating concerns and supporting the person safely and respectfully.

The registered manager or delegated senior person must liaise with the service user, representatives and relevant professionals where necessary, including GPs, district nurses, palliative care teams, hospitals, ambulance services, social workers, advocates and commissioners.

Staff must ensure that emergency responders are shown any current DNACPR, ReSPECT, TEP or ADRT document that is available in the home. Staff must not obstruct or challenge emergency responders but must clearly communicate relevant information and any known concerns.

Where the service user moves between services, hospital, respite, family care or another setting, the registered manager must take reasonable steps to ensure that relevant DNACPR, ReSPECT, TEP or ADRT information is communicated lawfully and safely to those who need it.

10. Policy Review and Updates

This policy will be reviewed at least annually, or sooner if there are changes in legislation, CQC requirements, Resuscitation Council UK guidance, local NHS or ambulance procedures, safeguarding requirements, data protection requirements, learning from incidents, audit findings or changes in the services provided by {{org_field_name}}.

The registered manager is responsible for ensuring that staff are informed of any changes to this policy and that additional training, supervision or competency checks are completed where required.

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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