Station 33

Donald Duke

Age: 64 years old female

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis 

  • Ask what has led him to consider a DNACPR decision at this time (to explore the motivation behind his request and ensure it is well informed)
  • Ask how he is coping emotionally with the recent death of his brother (to show empathy and assess emotional readiness)
  • Ask about his main concerns or fears regarding resuscitation (to explore underlying motivations such as fear of suffering, poor quality of life, or witnessing a loved one’s experience)
  • Ask if he has any concerns about his health deteriorating over time
  • Ask if he has had any previous hospital admissions or serious health scares that may have influenced this decision
  • Ask if he is taking any regular medications or has had any medical condition that is not listed on his records 
  • Ask about social history including smoking, alcohol, drug use and occupation
  • Ask if he understands what CPR involves, including both benefits and risks, such as potential survival, likelihood of brain injury, or poor outcomes in some cases (to ensure informed decision-making)
  • Ask if he is aware that a DNACPR only applies to resuscitation, and that it does not affect access to other treatments like antibiotics, oxygen, pain relief, or hospital admission (to clarify common misconceptions)
  • Ask if he feels he has had enough information and time to make this decision
  • Ask if he has discussed his wishes with any family members or healthcare professionals before
  • Ask if he has considered completing an Advance Care Plan or Advance Directive/Living Will (to support long-term planning for future care preferences)

Example of explanation to patient​

Thank you for bringing this up today, Mr Duke. It’s a really important and personal decision, and I appreciate how thoughtfully you’ve considered it. I’m really sorry to hear about what happened to your brother — that must have been incredibly difficult to witness, and it’s completely understandable that it’s made you think deeply about your own wishes.

Just to make sure we’re on the same page — DNACPR stands for Do Not Attempt Cardiopulmonary Resuscitation.

CPR is an emergency procedure we use to restart someone’s heart after it stops beating. It can involve things like chest compressions, electric shocks, and sometimes a breathing tube to try and restart the heart

Now, CPR can help in some situations, but not in all. The chances of it being successful really depend on why the heart stopped in the first place, and whether your lungs, heart, or other organs were already struggling before CPR

While CPR might sound straightforward, the outcomes can vary a lot. In some cases, it can be lifesaving. But in others, particularly those who are older, have underlying health conditions, or whose organs are already under strain, CPR may not work as well. It can sometimes lead to complications or leave someone with a significantly reduced quality of life. 

Does that make sense so far? Any questions? 

A DNACPR form is a way of recording your wishes in advance, it means that if your heart were to stop, the medical team would not attempt CPR. It’s about respecting your choice, and it applies only to CPR, it doesn’t affect any other treatment, like antibiotics, oxygen, fluids, or hospital care. You would still receive all other appropriate care.

Mr Duke, I also want to explain an important point about DNACPR forms. While they are taken very seriously, they are not legally binding documents. That means, in a medical emergency, if doctors or paramedics don’t have access to the form or if there’s uncertainty about your wishes or the situation, they may use their clinical judgment to do what they believe is in your best interests at that time. 

If you want to make sure this decision is respected even if you’re unable to communicate in the future, you can consider writing what’s called an Advance Decision to Refuse Treatment — that makes your wishes legally binding in certain situations.

We will document it in your GP record, notify the ambulance service, and ideally have a copy easily accessible at home or with you, such as in your wallet or by the bedside.

I would encourage you, if you feel comfortable, to discuss this with your family or loved ones. It can help avoid confusion or distress later on and ensures everyone understands your wishes.

Also, please know, if you ever change your mind, you can absolutely let us know and we can review or cancel the DNACPR form at any time.

I can send you a leaflet that explains all this in more detail, so you can take some time to read and reflect, if that would be helpful. How does all of this sound so far?

Management

Management

  • Acknowledge and explore the patient’s request for DNACPR sensitively, confirming he has capacity and has understood the implications.
  • Provide clear explanation of what DNACPR means — that it applies only to CPR and does not affect access to other treatments (e.g. antibiotics, fluids, hospital admission, pain relief).
  • Clarify that DNACPR is not legally binding, but is a clinically respected decision that guides healthcare professionals. 
  • Reassure the patient that his wishes will be documented and respected, and that the form can be reviewed if he ever changes his mind.
  • Encourage discussion with his wife and family, while making it clear that the final decision is his, to help reduce confusion or distress later.
  • Offer a face-to-face appointment (if needed) to complete the DNACPR form, ensuring documentation is clear, signed, and added to the patient’s record and summary care record.
  • Offer information leaflet or written material to support his understanding of DNACPR and advance care planning.
  • Explore broader future planning, such as completing an Advance Decision to Refuse Treatment (ADRT) or Advance Care Plan, if he would like to ensure other preferences are recorded.
  • Advise the patient to contact the surgery if he changes his mind or wishes to review the decision at any point in the future.

Learning point from this station: ​

While DNACPR forms are important clinical tools used to respect a patient’s wish not to undergo CPR, it is essential to understand that DNACPR is not legally binding. As clarified by the Resuscitation Council (UK), a “DNACPR decision is made and recorded to guide the decisions and actions of those present should the person suffer cardiac arrest, but is not a legally binding document.

Healthcare professionals are expected to respect DNACPR decisions as far as reasonably possible, but in a crisis, clinical judgment and the patient’s best interests will guide care — particularly if the DNACPR form is not available at the point of care.

If a patient wishes to ensure their refusal of resuscitation cannot be overridden, they should be advised to complete a legally binding Advance Decision to Refuse Treatment (ADRT) that specifically addresses resuscitation. Under the Mental Capacity Act 2005 (England & Wales), for an ADRT to refuse CPR to be valid and enforceable, the following criteria must be met:

  • The individual must be 18 years or older.
  • The patient must have mental capacity at the time of making the decision.
  • The refusal must be clearly written, signed, and witnessed.
  • It must state that the decision applies even if life is at risk.
  • It must be applicable to the exact clinical situation that arises in future.

In addition to an ADRT, patients may consider appointing a Lasting Power of Attorney (LPA) for health and welfare decisions, including life-sustaining treatment, should they lose capacity.

Patients should be informed that in emergency situations, if the DNACPR or ADRT is not available to clinicians, care may be given based on best interests. To avoid this, copies should be stored in the GP record, hospital records, with the ambulance service, and ideally kept easily accessible at home or on their person.

Regional Differences

Scotland and Northern Ireland do not have ADRTs underpinned by statute but rely on common law principles.

The Resuscitation Council (UK) states that decisions in these jurisdictions would be guided by similar principles used in English case law.

For an advance refusal to be considered valid in Scotland or Northern Ireland, the following factors are usually required:

  • The person was at least 16 years old in Scotland, and 18 years in Northern Ireland at the time of the decision.
  • They had mental capacity.
  • The circumstances described in the advance decision match those at the time CPR would be considered.
  • The decision was made voluntarily, without undue influence.

Understanding these legal frameworks ensures that GPs support patients’ autonomy while acting within the boundaries of the law and professional guidance.  

Further reading