Makindo Medical Notes

A DNACPR form is a medical decision that CPR should not be attempted if a patient has a cardiac arrest. It is not about stopping treatment in general — all other appropriate care (fluids, antibiotics, oxygen, analgesia, etc.) continues. In older adults, DNACPR is common because of frailty, multimorbidity, and limited likelihood of CPR success.

📊 CPR Outcomes in the Elderly

• 📉 Hospital survival after CPR in patients ≥80 is <10%.
• 🧠 Even if ROSC is achieved, risk of severe hypoxic brain injury is high.
• ⚖️ Frailty, comorbidities, and underlying illness strongly reduce CPR benefit. For those with severe frailty (CFS ≥7): ~2–3% survival to discharge, often with major neurological disability. With very high frailty (CFS 8–9): ~0–1% survive to hospital discharge.

⚖️ Legal & Ethical Framework (UK)

• 🧠 Mental Capacity Act 2005: Assume capacity unless proven otherwise. Assess decision-specific capacity.
• 👥 Patient involvement: If the patient has capacity, they must be involved in the decision.
• 📜 If no capacity: Decision made in best interests, considering family views, advance decisions, and values.
• 📄 Advance Decision to Refuse Treatment (ADRT): If valid & applicable, legally binding — must be respected.
• ⚖️ Court of Protection: Only needed if dispute cannot be resolved.

📊 Cardiac Arrest Survival by Frailty (CFS)

Survival after in-hospital cardiac arrest declines steeply with increasing frailty. Even if return of spontaneous circulation (ROSC) is achieved, neurological outcomes are usually poor in severe frailty.

🛠️ Process of Making a DNACPR Decision

1. 🔍 Assess likelihood of CPR success (frailty, comorbidities, illness severity).
2. 👩‍⚕️ Involve the patient if they have capacity.
3. 👨‍👩‍👧 If lacking capacity, discuss with family/carers — but remember: relatives cannot make the decision, they inform best interests.
4. 📝 Document reasoning clearly in notes + DNACPR form.
5. 📤 Communicate with wider healthcare team, care home, ambulance service.

🛡️ Communication Pearls

• 💬 Be clear: “This is only about CPR if the heart stops, not about other treatments.”
• ⚖️ Use sensitive language: “CPR is unlikely to work / may cause more harm than benefit.”
• 🌱 Emphasise what care will continue (comfort, symptom relief, treatments for reversible problems).
• 🧠 Explore values: “What matters most to you in terms of future care?”
• 📋 Involve palliative care/geriatrics team for complex discussions.

🚨 Common Misconceptions

• ❌ DNACPR ≠ “do not treat” — all appropriate medical care should continue.
• ❌ Families do not sign DNACPR — the decision is medical, but families are consulted.
• ❌ DNACPR ≠ euthanasia — it is withholding a burdensome and ineffective treatment.

🧑‍⚕️ Clinical Scenarios

📝 OSCE / Exam Pearls

• Always start by explaining what CPR is and its success rates in the elderly.
• State: “This does not mean we stop treating infections, pain, or other problems.”
• Mention legal framework: capacity, best interests, ADRT, LPA.
• Demonstrate sensitivity and clear communication skills.