LILACFORMSTAYSWITHPERSONWHEREVERTHEYAREBEINGCAREDFOR.WHITEFORMSFORAuDITANDNOTES.

UNIFIEDDONOTATTEMPTCARDIOPULMONARYRESUSCITATION(DNACPR)

IntheeventofcardiacorrespiratoryarrestnoattemptsatCPRwillbemade.Allotherappropriatetreatmentandcarewillbeprovided.

Name Address

DateofDNACPRDecision

//

(Central)

Postcode Dateofbirth//

NHSorhospitalnumber

InstitutionName

Formcompletedelectronically?YesNoBeforecompletingthisform,pleaseseeexplanation notes.

1.ReasonforDNACPRdecision

A)CPRisunlikelytobesuccessfuldueto

ThepersonhasbeeninformedofthedecisionYes / No / IfNostatereason
Therelevantotherhasbeeninformedofthedecision Yes / No / IfNostatereason

Nameofrelevantother

B)CPRmaybesuccessful,butfollowedbyalengthandqualityoflifewhichwouldnotbeofoverallbenefittotheperson.

•Personinvolvedindiscussions?YesNoIfnostatereason

•PersonlacksmentalcapacityandhasalegallyappointedWelfareAttorney:Name

•PersonlacksmentalcapacityanddoesnothavealegallyappointedWelfareAttorney.Decisionismadeonthebalanceof overall benefitto thepersonin discussionwith:Name(s)

C)There isavalidadvancedecisiontorefuseCPRinthefollowingcircumstances: AllcircumstancesYes No

SpecificCircumstances(pleasestate)

AttachacopyoftheAdvanceDecisiontoRefuseTreatment(ADRT)tothebackoftheDNACPRform.

2.HealthcareprofessionalmakingthisDNACPRdecision:

NamePositionGMC/NMC Signature Date / / Time :

Ifdecisionhasbeenmadebyadelegatedprofessional,thedecisionneedstobeverifiedattheearliestopportunity:

NamePositionGMC/NMC Signature Date / / Time :

3.Review:(SelectONEboxonly)This isan indefinite decisionNeedsreviewing

Reviewdateifappropriate//Outcomeofreview:DNACPRtocontinue?YesNo

NamePositionGMC/NMC Signature Date / / Time :

4.WhohasbeeninformedofthisDNACPRdecision?

GPAmbulanceWarning FlagOutofHours

CareProvider(Pleasestate)

Other(Pleasestate)

5.Otherimportantinformation:

Forexample,Ambulance crewinstructionson transfer,Ceilingsoftreatment,Preferredplaceof care/death.

Name Address

Postcode Dateofbirth//

NHSorhospitalnumber

TheDNACPRformislocated:

UNIFIEDDONOTATTEMPTCARDIOPULMONARYRESUSCITATION(DNACPR)

Considerusingthisform(aspartofAdvanceCarePlanning(ACP)),ifyouwouldnotbesurprisedifthepatientweretodieinthenextyear.FormoreinfoonACPpleaseaccessthetoolkitat

ThisisnotanAdvanceDecisiontoRefuseTreatment(ADRT).

ExplanationNotes Thisformshouldbecompletedlegiblyinblackballpointink

•Theperson’sfullname,NHSorHospitalnumber,dateofbirth,dateofwritingthedecisionandinstitutionnameshouldbecompletedandwrittenclearly.Addressmaychangeduetoperson’sdeterioratione.g.intoanursinghome.Ifallotherinformationiscorrecttheformremainsvalidevenwithincorrectaddress.

•Ifthedecisioniscancelledtheformshouldbecrossedthroughwith2diagonallinesinblackball-pointinkand“CANCELLED”writtenclearlybetweenthem,signedanddatedbythehealthcarestaff.ItistheresponsibilityofthehealthcarestaffcancellingtheDNACPRdecisiontocommunicatethistoallpartiesinformedoftheoriginaldecision(seesection4.onform).

•Electronic formmust beprintedand signedonlilac paperandcopies keptforaudit purposesandnotes.

•Triplicateforms,keeptogetheruntilpersonisdischarged/diesordecisioniscancelled.Lilacwiththeperson,1stwhitecopyforauditand2ndwhitecopyretaininthenotes.

Compulsorysectionsoftheform:Topsection,Section1andSection2.

1. / ReasonforDNACPR decision
1.A / CPRisunlikelytobesuccessful / SummaryofthemainclinicalproblemsandreasonswhyCPRwouldbeinappropriate,unsuccessfulornotintheperson’sbestinterest’s.Beasspecificaspossible.Inthissituationdiscussionwithperson/relevantotherisnotcompulsory,althoughitisconsideredbestpracticetoinformthepersonofthedecision,ifthepersonisdischargedhometheyneedtoknowaboutthedecision.Recordthedetailsofdiscussionorthereasonfornotdiscussingintheperson’snotes.
1.B / CPRmaybesuccessful,butmaybefollowedbyalengthandqualityoflifewhichwouldnotbeofoverallbenefittotheperson / Summaryofcommunicationwithperson…
Stateclearlywhatwasdiscussedand agreed.Ifthisdecisionwasnot discussedwiththepersonstatethereasonwhythiswasinappropriate.
If the persondoes nothave capacitytheir relativesor friendsmust be consultedand maybe ableto helpbyindicatingwhatthepersonwoulddecideifabletodoso.Ifthereisnooneappropriatetoconsult
andthepersonhasbeenassessedaslackingcapacitythenaninstructiontoanIndependentMentalCapacityAdvocate(IMCA)mustbeconsidered.IfthepersonhasmadeaLasting PowerofAttorney(LPA),appointingaWelfareAttorneytomakedecisionsontheirbehalf,thatpersonmustbeconsulted.AWelfareAttorneymaybeabletorefuselife-sustainingtreatmentonbehalfofthepersonifthispowerisincludedintheoriginalLastingPowerofAttorney.YouneedtocheckthisbyreadingtheLPA.
If thepersonhascapacityensure thatdiscussionwithothersdoesnot breachconfidentiality.
Statethenamesandrelationshipsofrelatives/relevantotherswithwhomthisdecisionhasbeendiscussed.Moredetaileddescriptionofsuchdiscussionshouldberecordedintheclinicalnoteswhereappropriate.
1.C / DNACPRisinaccordwiththerecorded,sustainedwishesofthepersonwhoismentallycompetent. / CheckforthevalidityandapplicabilityoftheAdvanceDecisiontoRefuseTreatment(ADRT).IstheADRT
–1.SpecifictoCPR?2.Inwriting,signedandwitnessed?
3.Containsthestatement‘eveniflifeisatrisk’4.HasthepersonbeenconsistentwiththeirADRT?
Ifthe answer to all the above is‘Yes’ theADRT is valid and applicable.
IftheADRTcontainsspecificcircumstanceswhenCPRwouldnotbeappropriatewritetheseontheform.AttachacopyoftheADRT totheperson’sDNACPRform.
2. / PersonmakingthisDNACPRdecision/Verification / Statenamesand positions.Ingeneralthisshouldbethemostseniorhealthcareprofessionalimmediatelyavailable.Ifthedecisionismadebyadelegatedprofessionalitmustbeverifiedbythemostseniorhealthcareprofessionalresponsiblefortheperson’scareattheearliestopportunity.Ifthepersonmakingthedecisionisthemostseniorperson,verificationisnotrequired.
3. / Review / Afixedreviewdateisnotrecommended.This decisionwillberegardedas“INDEFINITE”unless:
i)adefinitereviewdateisspecified
ii)there are changesin theperson’s condition
iii)theirexpressedwisheschange
Reviewerneedstocompletealldetailsontheformanddocumenttheoutcomeinthenotes.
4. / WhohasbeeninformedofthisDNACPRdecision? / Pleaseensurethatallhealthandsocialcarestaffwhohavebeeninformedareawareoftheirresponsibilitytodocumentthedecisionintheirownrecords,astheoriginalstayswiththeperson.Itistheresponsibilityofhealthandsocialcarestafftoensurethosewhohavebeeninformedofthedecisionareinformedifthepatientdies,ortheformiscancelled.
5. / OtherImportantInformation / Thisinformationneedsto beveryclearand precise.For example,iftransferringincludename,
addressandtelephonenumberofdestinationandnextofkin.CeilingsoftreatmentincludewhereACPiskept.Preferredplaceofcareshouldbenoted.
Tearoffslip / Completedetailsandplacein “messageinabottle”ifavailablewithlocationclearlystated. Forexample,‘Inthenursingnotesinthetopdrawerofthesideboardinthediningroom.’

•ForfurtherinformationregardingEoLC,orderingnew DNACPRforms,forthepolicyorfortheelectronicformaccess: