Few pieces of paper in a care home carry as much weight as a DNACPR form, and few are as widely misunderstood. Staff are unsure whether it means 'do not treat', families think they can sign one, and forms sit in the wrong folder, out of date, or missing when the ambulance arrives. This guide explains what a DNR or DNACPR decision is, who makes it, how the ReSPECT process fits in, what staff actually do in an emergency, and how a home keeps the decision visible, current and lawful.
The short answer
A DNACPR decision (do not attempt cardiopulmonary resuscitation), often called a DNR, is a clinical decision that if the person's heart or breathing stops, CPR will not be attempted. It is made by the senior clinician responsible for the person, usually the GP or a hospital consultant, after discussion with the person or, if they lack capacity, with the people close to them. It applies to CPR only. It does not mean the person should not be treated, fed, given antibiotics, taken to hospital or kept comfortable. The care home's job is to make sure the decision is known, the form is where staff and paramedics can find it, the person and family understand it, and it is reviewed when things change.
What is a DNR?
DNR stands for 'do not resuscitate'. The term most UK services now use is DNACPR, 'do not attempt cardiopulmonary resuscitation', because the word 'attempt' is more honest: CPR on a frail older person rarely succeeds and often causes injury, and the decision is about whether an attempt is likely to work or to be wanted. You will also see DNAR, 'do not attempt resuscitation'. All three mean the same thing in a care home.
The decision sits on a form. In England there is no single national form, so the design depends on the area. Many areas now use the ReSPECT form, which records the DNACPR decision as part of a wider plan. Others still use a stand-alone DNACPR form, usually with a red border, so it is easy to spot.
What a DNACPR decision does and does not mean
The single most important thing for staff to understand is the scope. A DNACPR decision answers one question: if this person's heart stops or they stop breathing, should anyone start chest compressions and rescue breaths? Everything else continues.
| A DNACPR decision means | A DNACPR decision does not mean |
|---|---|
| CPR will not be attempted if the heart or breathing stops | The person should not go to hospital |
| The clinician has judged that CPR would not work, or the person does not want it | The person should not have antibiotics, fluids or other treatment |
| Staff still call for help in line with the home's procedure | Staff stop checking, repositioning or feeding the person |
| Comfort, dignity and symptom control remain the priority | Choking, falls or seizures go untreated |
The last row matters in practice. If a resident with a DNACPR form chokes, staff clear the airway with back blows and abdominal thrusts as they would for anyone, because choking is not a cardiac arrest. If they fall and break a hip, they go to hospital. If they have a seizure, the seizure protocol applies. The form only becomes relevant if the heart or breathing actually stops.
Who makes the decision?
The decision belongs to the most senior clinician responsible for the person's care at the time: usually the GP in a care home, or a consultant if the person is in hospital. Some advanced nurse practitioners and other senior clinicians are authorised to make and sign decisions under local policy.
Care home staff, managers, families and social workers cannot make a DNACPR decision. A family member cannot 'sign a DNR' on someone's behalf. What the family can do is share what the person would have wanted, and the clinician must take that into account.
When the person has capacity
If the person has capacity to be involved, the clinician must discuss the decision with them, unless doing so would cause physical or psychological harm. The Court of Appeal made this clear in the Tracey case in 2014. A person with capacity can refuse CPR, and that refusal should be respected. They cannot insist on CPR that a clinician judges will not work, but they are entitled to know a decision has been made and to ask for a second opinion.
When the person lacks capacity
If the person lacks capacity to take part in the discussion, the clinician must consult the people close to them: family, friends, an attorney under a health and welfare lasting power of attorney, or a deputy. If there is nobody appropriate to consult, the clinician should involve an independent mental capacity advocate where the Mental Capacity Act requires it. The Winspear case in 2015 confirmed that failing to consult the family of a person who lacked capacity breached their rights.
The care home should record that this consultation happened. If a GP sends back a signed form and the family say nobody spoke to them, raise it with the GP the same day.
DNACPR decisions in learning disability services
Learning disability is never, on its own, a reason for a DNACPR decision. Nor is autism, Down's syndrome or a mental health condition. A decision has to be based on the person's actual clinical situation and, where possible, their wishes.
This needs saying because it has gone wrong. CQC's review of DNACPR decisions during the pandemic found inappropriate and blanket decisions, including for people with a learning disability, and the Learning from Lives and Deaths reviews have repeatedly found forms giving 'learning disability' or 'Down's syndrome' as the reason. If a resident in your service has a form that cites the disability as the reason, or you suspect the decision was made without proper discussion, ask the GP to review it and record that you asked. That is a safeguarding issue, not an administrative one. Our article on LeDeR, STOMP and annual health checks covers the wider health duties.
DNACPR and advance decisions are different
An advance decision to refuse treatment, sometimes called a living will, is made by the person themselves while they have capacity, under the Mental Capacity Act 2005. If it is valid and applicable, it is legally binding. An advance decision refusing life-sustaining treatment, including CPR, must be in writing, signed and witnessed, and must state that it applies even if life is at risk.
A DNACPR form is a clinical decision and is not legally binding in the same way. It is a clear record of a decision that clinicians and paramedics will follow, but a clinician could in principle reach a different decision if circumstances change.
A care home may have residents with both. Keep a copy of any advance decision with the care plan, make sure the GP knows it exists, and make sure it is referenced on the emergency summary.
What is the ReSPECT process?
ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. It was developed by the Resuscitation Council UK with other professional bodies and is now used across many areas of England and Scotland. Instead of a form that only covers CPR, ReSPECT records the person's preferences and the clinical recommendations for a range of emergencies: whether hospital admission is wanted, whether the focus is on prolonging life or on comfort, and the CPR decision.
For a care home, ReSPECT is more useful than a stand-alone DNACPR form because it answers the questions staff actually face at 3am: do we send her in, what does he want, who do we ring. Where your area uses ReSPECT, every resident should ideally have one, including those for whom CPR would be attempted, because the rest of the plan still matters.
Where the form lives
A decision nobody can find is no decision at all. In an emergency, paramedics will ask for the form within seconds of arriving. The original should be immediately available in the home, and should go with the person if they are transferred to hospital.
- Keep the original in an agreed place every staff member knows, often the front of the care file or a dedicated emergency folder by the office.
- Record the decision on the person's profile and in the emergency summary, so it appears on the handover sheet and the hospital passport.
- Make sure the form goes with the person on any transfer, and is returned or replaced when they come back.
- Follow local policy on copies. Some areas accept clear copies; others want the original. Know which yours is.
- Tell agency and bank staff at the start of every shift which residents have a decision in place.
A digital record helps here, because the status shows on the person's profile on every device rather than sitting in one paper file. It does not replace the signed form, which is what the paramedic will ask to see.
What staff do in an emergency
Every home needs a written procedure, and every member of staff should be able to describe it. In outline:
- If someone collapses, check for a response and normal breathing as you would for anyone.
- If they are choking, bleeding, fitting or have fallen, treat that emergency. The DNACPR decision does not apply.
- If they are not breathing normally and have no signs of life, check immediately whether a valid DNACPR decision is in place. The senior on shift should know without looking it up.
- If there is a valid decision, do not start CPR. Stay with the person, keep them comfortable and dignified, and follow the home's procedure for contacting the GP, 111 or 999. Many homes call 999 so a clinician can attend and confirm the situation; follow your local policy.
- If there is no decision, or there is any doubt about whether the form is valid or applies to this person, start CPR and call 999. Doubt always means resuscitate.
- Record what happened, the time, who was present and who was informed.
The doubt rule is important. Staff are never criticised for starting CPR when they could not find the form or were not sure it was current. They can be criticised, and the person can be harmed, when CPR is withheld on a guess.
Reviewing a DNACPR decision
Many forms say 'indefinite' and many areas no longer use expiry dates, because a fixed review date creates a risk of a form being treated as invalid simply because the date has passed. But indefinite does not mean forever. The decision should be reviewed when:
- the person's condition changes significantly, for better or worse;
- the person moves home or is admitted from hospital with a new form;
- the person, or the people close to them, ask for a review;
- the form contains an error, or cites a reason that is not lawful, such as the learning disability alone;
- the care plan is reviewed and the decision no longer seems to fit.
Put the DNACPR status on the care plan review checklist so it is looked at every time, and record the outcome even when nothing changes. Our guide to how often care plans should be reviewed explains how to build that into a cycle.
Talking to residents and families
Families often hear about a DNACPR decision for the first time when they see the red form, and the conversation goes badly. The home did not make the decision, but the home is where they are when they find out.
Good practice is to make advance care planning part of normal care rather than a crisis conversation. Ask on admission, in plain language, what matters to the person, what they would want if they became very unwell, and whether there is anything they would not want. Record it in their own words. Use easy-read materials where they help. When a GP is considering a decision, make sure the person and family know the conversation is coming and who to speak to.
If a family member disagrees with a decision, they cannot overrule it, but they can ask the clinician to explain and can request a second opinion. Help them do that. Record that the concern was raised and passed on.
Linking it to end of life care planning
A DNACPR decision is one line of a much bigger plan. The end of life section of the care plan should cover where the person wants to be, who they want with them, faith and cultural wishes, symptom control, anticipatory medicines, and what should happen after death. Our guide to writing a person-centred care plan covers the end of life section, and the hospital passport guide explains how to make sure the decision travels with the person.
Worked example: Edith
Edith is 88, has heart failure and moderate dementia, and has lived in a residential home for two years. After a hospital admission, she comes back with a DNACPR form signed by a consultant. Her daughter was not consulted.
The senior on shift checks the form, finds no record of discussion with the family, and tells the manager. The manager rings the GP, who visits, speaks with Edith (who can say she does not want 'machines and pumping') and with her daughter, and completes a ReSPECT form that records the DNACPR decision, a preference to avoid hospital unless there is a reversible problem, and that comfort comes first. The home updates Edith's profile, her emergency summary and her hospital passport, files the original ReSPECT form in the agreed place, and briefs the night staff. Three weeks later Edith develops a chest infection. Staff ring the GP, who prescribes antibiotics, and Edith recovers at home, which was exactly what the plan said she wanted.
Worked example: Jordan
Jordan is 34, has a moderate learning disability and epilepsy, and lives in a supported living service. On a review of his file, the new manager finds a DNACPR form from a hospital admission four years earlier. The reason box says 'learning disability, epilepsy'.
The manager raises it with the GP and the community learning disability team the same day, records that she has done so, and treats it as a safeguarding concern. The GP reviews Jordan, finds no clinical reason for the decision, speaks with Jordan and his mother, and cancels the form. The cancellation is recorded and the old form is marked as cancelled, not simply removed, so the history is clear.
Common mistakes
- Staff believing a DNACPR form means 'do not treat' or 'do not send to hospital'.
- Forms kept in a filing cabinet nobody can open at night.
- No record of discussion with the person or the family.
- Learning disability, age or dementia given as the reason.
- Agency staff not told which residents have a decision in place.
- Forms not travelling with the person to hospital, or not coming back.
- A care home manager or family member 'signing' a form.
- No review when the person's condition changes.
What good looks like on inspection day
An inspector asks a carer what they would do if a particular resident collapsed. The carer knows whether that resident has a DNACPR decision, knows where the form is, says they would still treat choking or a fall as normal, and says that if they were ever unsure they would start CPR and call 999.
The inspector looks at the file and finds the signed form, a record of who was consulted and when, the decision reflected in the care plan, the emergency summary and the hospital passport, and a dated review. For a resident with a learning disability, they find a decision based on clinical reasons, not on the disability. If you want to see how emergency status, care plans and hospital passports sit together in one record, book a demo.
Final conclusion
A DNACPR decision is a narrow clinical decision with wide consequences. The home does not make it, but the home is responsible for making it work: knowing who has one, keeping the form where it can be found in seconds, making sure staff understand that it covers CPR and nothing else, challenging decisions that look wrong, and reviewing it when life changes. Get those habits right and the form does what it is meant to do, which is to protect the person from an intervention they would not want, without ever denying them the care they need.
Frequently asked
What is a DNR?
DNR stands for 'do not resuscitate'. Most UK services now use the term DNACPR, 'do not attempt cardiopulmonary resuscitation'. It is a clinical decision that CPR will not be attempted if the person's heart or breathing stops. It does not affect any other care or treatment.
Who can sign a DNACPR form?
The senior clinician responsible for the person, usually the GP or a hospital consultant, or another clinician authorised under local policy. Care home staff, managers and family members cannot make or sign the decision, although the clinician must consult the person or, if they lack capacity, the people close to them.
Does a DNACPR form mean the person should not go to hospital?
No. A DNACPR decision covers CPR only. The person should still receive every other appropriate treatment, including hospital admission, antibiotics and treatment for choking, falls or seizures, unless a separate plan such as ReSPECT records a different preference.
What is the difference between DNACPR and ReSPECT?
A DNACPR form records only the CPR decision. ReSPECT is a wider emergency care plan that records the person's preferences and clinical recommendations, including whether hospital admission is wanted and whether the focus is on prolonging life or on comfort, alongside the CPR decision.
Can a family member refuse a DNACPR decision?
A family member cannot overrule a clinical DNACPR decision, but if the person lacks capacity the family must be consulted, and they can ask the clinician to explain and can request a second opinion. A health and welfare attorney has a stronger role and must be involved.
Can a learning disability be a reason for a DNACPR decision?
No. A learning disability, autism or Down's syndrome is never on its own a lawful reason for a DNACPR decision. If a form gives the disability as the reason, ask the GP to review it and treat it as a safeguarding concern.
What should staff do if they cannot find the form?
Start CPR and call 999. If there is any doubt about whether a valid decision exists or applies to this person, staff should always attempt resuscitation.
How often should a DNACPR decision be reviewed?
Whenever the person's condition changes significantly, they move or return from hospital, they or their family ask, or the care plan is reviewed. Many areas no longer use fixed expiry dates, but indefinite does not mean the decision should never be looked at again.
Sources
- Resuscitation Council UK: ReSPECT process and guidance
- British Medical Association, Resuscitation Council UK and Royal College of Nursing: Decisions relating to cardiopulmonary resuscitation
- Mental Capacity Act 2005 and its Code of Practice, advance decisions to refuse treatment
- R (Tracey) v Cambridge University Hospitals NHS Foundation Trust [2014] EWCA Civ 822
- Winspear v City Hospitals Sunderland NHS Foundation Trust [2015] EWHC 3250 (QB)
- CQC: Protect, respect, connect, decisions about living and dying well during COVID-19
- LeDeR: Learning from Lives and Deaths annual reports
