FAQs: Emergency treatment plans and recommendations about CPR

Emergency treatment plans refer to processes that recommend what interventions may, or may not be, appropriate for someone if they become suddenly unwell. They are written by healthcare professionals to provide immediate guidance to those who have a duty to respond to medical emergencies.
Emergency treatment plans, such as ReSPECT and DNACPR, are not legally binding. 

Historically, DNACPRs (Do Not Attempt Cardiopulmonary Resuscitation) have been used to provide recommendations about whether CPR should be provided in the event of cardiac arrest.

However, Resuscitation Council UK now encourages the use of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process in clinical practice. The process allows clinicians to create personalised recommendations for a person’s clinical care and treatment in a future emergency in which they are unable to make or express choices. Recommendations are made through conversations between the individual, their families, and healthcare professionals and recorded on a plan which can be recognised across all care settings. 

DNACPR only provides a recommendation not to attempt CPR if a person suffers a cardiac arrest. Whilst a person may have a copy of their DNACPR, it is generally held as part of their medical notes.

In contrast, as well as recording whether CPR attempts are recommended or not, the ReSPECT process provides a framework to help people and healthcare professionals discuss and record what other emergency treatments are recommended or not, so a shared understanding is reached. Once a ReSPECT plan has been written, a copy of this must be given to the person for them to keep hold of.

There are several reasons why it may not be appropriate for people to be offered, or receive, all available resuscitation and emergency treatments when they are unwell. 

In some instances, this may be because the intervention may not be clinically appropriate for that person as it may be unlikely to offer any benefit or could even risk causing harm. In these circumstances, a healthcare professional should explain clearly to that person, or those close to them, why this is the case.

Some people may not wish to receive specific emergency treatments. In this circumstance, it is important for people to have the opportunity to discuss their wishes with a healthcare professional who can help that person make an informed decision about if this choice is right for them.

For CPR in particular, it is important people are given a full understanding of this treatment, its implications and if it will likely offer them any benefit if they suffer a cardiac arrest.

When someone’s heart and breathing stop because they are dying from an advanced and irreversible condition, CPR will subject them to a vigorous physical intervention that deprives them and those important to them of a dignified death. For some people this may prolong the process of dying and, in doing so, prolong or increase suffering.

CPR is by no means always successful in restarting the heart and breathing. When CPR is shown in films and TV ‘soaps’ they often fail to show the reality of what is involved and of the likelihood of success.

Recommendations in a person’s emergency treatment plan are intended to be read by healthcare professionals responding to a medical emergency. They are used to provide immediate guidance to help inform decision-making in an emergency. 

A previously recorded recommendation not to provide CPR should not override clinical judgment at the time of an emergency.

If someone who has a DNACPR, or a ReSPECT plan where CPR attempts are not recommended, has a cardiac arrest due to an unforeseen and potentially reversible cause that was not envisaged when their plan was written, such as choking, then it may be appropriate for CPR to be provided until specialist help arrives.

Other examples of such reversible causes might include anaphylaxis, a displaced tracheal tube or a blocked tracheostomy tube.

An Advance Decision to Refuse Treatment (ADRT) is (as defined in the Mental Capacity Act 2005 – England & Wales) a legally binding document that the person has drawn up (when they had the capacity to make decisions) and in which they have stipulated certain treatments, such as CPR, that they would not wish to receive, and the circumstances in which those decisions would apply.

Where a properly made and applicable ADRT refuses CPR (acknowledging that their life would be at risk), a healthcare professional who knowingly disregards it and attempts CPR could be exposed to a civil claim for battery (unauthorised touching).

No, you don’t have to if you don’t want to.

However, if you want to be sure that what's important to you is respected it is important that people close to you know what they are and where they have been recorded.

A decision not to recommend specific emergency treatments, such as CPR, only relates to that specific treatment and should not affect the quality of care or any other treatment that you receive. 

No. Each person is an individual whose needs and preferences must be taken into account in the context of their overall health and medical history. Blanket policies are inappropriate, whether due to medical condition, disability, or age. This is particularly important in recommendations around not resuscitating a person, which should only ever be made on an individual basis and in consultation with the individual or their family/Lasting Power of Attorney.

No. The recommendation whether to perform CPR should be discussed within the broader context of their overall goals of care and treatment. It is essential to understand what is important to them and what they would or would not want in an emergency. The recommendation on whether to perform CPR is only one part of this.

If a person is unable to contribute to recommendations (for example, because they are unconscious, too severely ill, or lack the mental capacity to participate in the discussion), the senior clinician responsible for their care will make the recommendation, whenever possible, after taking advice from those close to the person, such as family members.

Family members are not expected or entitled to make recommendations around CPR unless they have been given legal power (e.g. Lasting Power of Attorney) to make such recommendations on the person’s behalf.
 

If you have concerns or questions about the contents an emergency treatment plan, you should contact a clinician with senior responsibility for the care of the person the plan relates to, to discuss this further. In the community this could be a GP, or a consultant in hospital.

Further information for the public and healthcare professionals about the ReSPECT process can be found here.

The British Medical Association, Resuscitation Council UK and Royal College of Nursing have published detailed national guidance on decisions about CPR. Whilst this is written mainly to guide healthcare professionals, some members of the public have found it helpful when they were seeking answers to specific questions.

The NHS offers further information on DNACPR and ADRT decisions here.

In addition, for people with implanted cardiac devices (such as implantable cardioverter-defibrillators or pacemakers) Resuscitation Council UK, British Cardiovascular Society and National Council for Palliative Care have published detailed guidance for professionals, and (in collaboration also with the British Heart Foundation and Arrhythmia Alliance) an information leaflet for patients and their carers. Both resources can be found here.

Further information on decision-making towards the end of life and on ADRTs is available on the Compassion in Dying website.

If you have an ADRT, a healthcare professional might recommend you also have a ReSPECT plan. 
A ReSPECT plan can be used to draw attention to the presence of an ADRT and should contain relevant aspects within the summary recommendations for treatment and care. If you would like to find out more about ADRTs, visit the NHS Advance decision to refuse treatment (living will) page.

This will depend on the region where you live.

In many areas where the ReSPECT process has been adopted, particularly in England, it has replaced DNACPR, and nothing additional is needed.

In some adopting areas, such as certain parts of Scotland, recommendations not for CPR still require DNACPR forms to be completed alongside a ReSPECT plan. The healthcare professional completing the process with you should advise you if this is necessary.

A ReSPECT plan summarises the emergency care aspect of a wider advance or anticipatory care planning process. ReSPECT records information to make it rapidly accessible to professionals who need to make immediate decisions about care and treatment in a crisis. An ACP or EOL plan document is usually longer and more detailed than ReSPECT. It is not restricted to planning for an emergency and is likely to contain more information.

Whilst a ReSPECT conversation should ideally be held face to face to facilitate effective communication and so a single version of a plan can be updated, you can have a ReSPECT conversation and update an existing plan by telephone, assuming you have the same version as the patient.

If a plan is updated or recommendations are changed, then a newly agreed copy of the plan must be sent to the patient, and the patient should be advised to score through the “old” plan and write ‘CANCELLED’ clearly on the plan.

Arrangements for the provision of ReSPECT training and resources are made at a local level. There should be a lead for ReSPECT in each locality. Please contact the ReSPECT lead in your area to find out what arrangements have been put in place. If you are unable to find out who is leading locally, then please get in touch, advising us of your locality, and we will try to refer your enquiry to the correct person.