Statement on advance care planning, including do not attempt cardio pulmonary resuscitation (DNACPR)

We know from people using services, patients, registrants and media reports that there are instances where advance care plans, including those with or without ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms, have been applied to groups of people in response to the Covid-19 pandemic.

The nature of this pandemic means that practitioners are under great pressure to make urgent, clinically complex decisions. To make sure that peoples’ wishes and preferences can be taken into account, the need for advanced care planning* with them and their families is more important than ever.

Discussions about approaches to future care can be distressing, but that should not mean that an individual or their family are not given the opportunity to talk about their wishes, needs and concerns. The discussion should be handled sensitively, taking account of each person’s needs and wishes.

Person centred individualised care is at the heart of clinical practice. The pandemic does not permit any health or care professional to deviate from that approach by making decisions on a group basis. Health and care professionals, including those in leadership roles must practice in line with their professional code¹ and in accordance with the principles of person-centred and individualised care. 

We fully recognise that advance care planning offers people the opportunity to plan their future care and support, including medical treatment, while they have the capacity to do so. Mental capacity legislation across the UK also provides a number of ways for people to plan their care and support in advance should their capacity to make decisions be limited or change.

When discussing advance care planning, every individual has the right to expect support and written information in accordance with their needs in a way that they can understand.

Where advance care planning includes discussions around putting in place a DNACPR² form or a recommended summary plan for emergency care and treatment (ReSPECT³ care plan), this requires thoughtful and compassionate handling. It is essential that these decisions are made on an individual basis involving the person concerned and those close to them along with the health and care team.

It is vital that all health and care professionals are open with people using services, patients, their families and carers about the clinical and other factors being taken into account in any decision about CPR/DNACPR. They should provide reassurance that if a DNACPR decision is made it does not mean that other appropriate treatments will cease - other options of care will still be available and should be discussed and agreed.

Current guidance⁴, a recently published joint statement⁵ and information from the devolved administrations⁶ are unanimous in reiterating how advance care plans should be made with people and patients, and in explicitly stating that decisions must be made on an individual basis. In particular General Practitioners (GPs) continue to have a central role in supporting patients and families or carers in the consideration and completion of DNACPR forms for people in community settings.

* We recognise that ‘advanced care planning’ may also be referred to as ‘anticipatory care planning⁷ in Scotland. We therefore intend for this statement to be applicable to care planning of either name.

Useful information

If you require further information, please refer to the following:

1. The professional codes from both the NMC and GMC:

• www.nmc.org.uk/code
• www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice

2. Information from the Resuscitation Council UK on DNACPR model forms and recommended standards for recording decisions

• www.resus.org.uk/dnacpr/do-not-attempt-cpr-model-forms/

3. Information from the Resuscitation Council UK on ReSPECT care planning

• www.resus.org.uk/respect/

4. NICE quick guide on advance care planning for registered managers of care homes and home care services

• www.nice.org.uk/Media/Default/About/NICE-Communities/Social-care/quick-guides/advance-care-planning-quick-guide.pdf

NICE guidance on decision-making and mental capacity

• www.nice.org.uk/guidance/ng108/resources/decisionmaking-and-mental-capacity-pdf-66141544670917 

NICE guidance on end of life care for infants, children and young people with life-limiting conditions: planning and management

• www.nice.org.uk/guidance/ng61/chapter/recommendations

5. Joint statement from British Medical Association, Care Provider Alliance, Care Quality Commission and Royal College of General Practice on advance care planning

• www.rcgp.org.uk/about-us/news/2020/april/joint-statement-on-advance-care-planning.aspx

6. Letter from Chief Nursing Officer and National Medical Director for England to NHS trusts, CCGs, primary care providers and providers of community health services

• www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/maintaining-standards-quality-of-care-pressurised-circumstances-7-april-2020.pdf

Guidance from the Welsh Government on ethical values and principles for healthcare delivery framework

• gov.wales/coronavirus-ethical-values-and-principles-healthcare-delivery-framework

Guidance and clinical advice on Covid-19 from the Scottish Government

• www.gov.scot/publications/coronavirus-covid-19-clinical-advice/

7. Information about anticipatory care planning during the Covid-19 pandemic from NHS inform:

• www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/coronavirus-covid-19/coronavirus-covid-19-making-a-plan-for-your-care-during-the-covid-19-pandemic

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