LILAC FORM STAYS WITH PERSON WHEREVER THEY ARE BEING CARED FOR.

WHITE FORMS FOR AuDIT AND NOTES.

UNIFIED DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION (DNACPR)
In the event of cardiac or respiratory arrest no attempts at CPR will be made. All other appropriate treatment and care will be provided.

Date of DNACPR Decision

Name
/ / (Central)
Address
www.southofengland.nhs.uk/what-we-are-doing/end-of-life-care
Postcode
Institution Name
Date of birth / /
Form completed electronically? Yes No
NHS or hospital number Before completing this form, please see
explanation notes.

1. Reason for DNACPR decision

A) CPR is unlikely to be successful due to

The person has been informed of the decision Yes No If No state reason
The relevant other has been informed of the decision Yes No If No state reason
Name of relevant other
B) CPR maybe successful, but followed by a length and quality of life which would not be of overall benefit to the person.
• Person involved in discussions? Yes No If no state reason
• Person lacks mental capacity and has a legally appointed Welfare Attorney: Name
• Person lacks mental capacity and does not have a legally appointed Welfare Attorney. Decision is made on the balance of
overall benefit to the person in discussion with: Name(s)
C) There is a valid advance decision to refuse CPR in the following circumstances: All circumstances Yes No
Specific Circumstances (please state)

Attach a copy of the Advance Decision to Refuse Treatment (ADRT) to the back of the DNACPR form.

2. Healthcare professional making this DNACPR decision:

Name Position GMC/NMC
Signature Date / / Time :
If decision has been made by a delegated professional, the decision needs to be verified at the earliest opportunity:
Name Position GMC/NMC
Signature Date / / Time :

3. Review: (Select ONE box only) This is an indefinite decision Needs reviewing
Review date if appropriate / / Outcome of review: DNACPR to continue? Yes No
Name Position GMC/NMC
Signature Date / / Time :

4. Who has been informed of this DNACPR decision?

GP Ambulance Warning Flag Out of Hours
Care Provider (Please state)
Other (Please state)

5. Other important information:

For example, Ambulance crew instructions on transfer, Ceilings of treatment, Preferred place of care/death.

Name
in
in

The DNACPR form is located:

Address
Postcode
Date of birth / /
and

NHS or hospital number

 UNIFIED DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION (DNACPR)
Consider using this form (as part of Advance Care Planning (ACP)), if you would not be surprised if the patient were to die in the
next year. For more info on ACP please access the toolkit at http://www.southofengland.nhs.uk/wp-content/uploads/2012/04/ACP-toolkit-v5.pdf
This is not an Advance Decision to Refuse Treatment (ADRT). www.adrt.nhs.uk
Explanation Notes This form should be completed legibly in black ball point ink
• The person‟s full name, NHS or Hospital number, date of birth, date of writing the decision and institution name should be
completed and written clearly. Address may change due to person‟s deterioration e.g. into a nursing home. If all other information
is correct the form remains valid even with incorrect address.
• If the decision is cancelled the form should be crossed through with 2 diagonal lines in black ball-point ink and “CANCELLED”
written clearly between them, signed and dated by the healthcare staff. It is the responsibility of the healthcare staff cancelling the
DNACPR decision to communicate this to all parties informed of the original decision (see section 4.on form).
• Electronic form must be printed and signed on lilac paper and copies kept for audit purposes and notes.
• Triplicate forms, keep together until person is discharged/ dies or decision is cancelled. Lilac with the person, 1st white
copy for audit and 2nd white copy retain in the notes.

Compulsory sections of the form: Top section, Section 1 and Section 2.

1. Reason for DNACPR

decision
1.A CPR is unlikely to be Summary of the main clinical problems and reasons why CPR would be inappropriate,
successful unsuccessful or not in the person‟s best interest‟s. Be as specific as possible. In this situation
discussion with person / relevant other is not compulsory, although it is considered best practice to
inform the person of the decision, if the person is discharged home they need to know about the
decision. Record the details of discussion or the reason for not discussing in the person‟s notes.
1.B CPR may be successful, Summary of communication with person…
but may be followed by State clearly what was discussed and agreed. If this decision was not discussed with the person state
a length and quality of the reason why this was inappropriate.
life which would not be If the person does not have capacity their relatives or friends must be consulted and may be able to help
of overall benefit to the by indicating what the person would decide if able to do so. If there is no one appropriate to consult
person and the person has been assessed as lacking capacity then an instruction to an Independent Mental
Capacity Advocate (IMCA) must be considered. If the person has made a Lasting Power of Attorney
(LPA), appointing a Welfare Attorney to make decisions on their behalf, that person must be consulted. A
Welfare Attorney may be able to refuse life-sustaining treatment on behalf of the person if this power is
included in the original Lasting Power of Attorney. You need to check this by reading the LPA.
If the person has capacity ensure that discussion with others does not breach confidentiality.
State the names and relationships of relatives / relevant others with whom this decision has been
discussed. More detailed description of such discussion should be recorded in the clinical notes where
appropriate.
1.C DNACPR is in accord with Check for the validity and applicability of the Advance Decision to Refuse Treatment (ADRT). Is the ADRT
the recorded, sustained – 1. Specific to CPR? 2. In writing, signed and witnessed?
wishes of the person who is 3. Contains the statement „even if life is at risk‟ 4. Has the person been consistent with their ADRT?
mentally competent. If the answer to all the above is „Yes‟ the ADRT is valid and applicable.
If the ADRT contains specific circumstances when CPR would not be appropriate write these on the
form. Attach a copy of the ADRT to the person‟s DNACPR form.
2. Person making this DNACPR State names and positions. In general this should be the most senior healthcare professional
decision/ Verification immediately available. If the decision is made by a delegated professional it must be verified by the
most senior healthcare professional responsible for the person‟s care at the earliest opportunity. If the
person making the decision is the most senior person, verification is not required.
3. Review A fixed review date is not recommended. This decision will be regarded as “INDEFINITE” unless:
i) a definite review date is specified
ii) there are changes in the person‟s condition
iii) their expressed wishes change
Reviewer needs to complete all details on the form and document the outcome in the notes.
4. Who has been informed of Please ensure that all health and social care staff who have been informed are aware of their
this DNACPR decision? responsibility to document the decision in their own records, as the original stays with the person. It is
the responsibility of health and social care staff to ensure those who have been informed of the decision
are informed if the patient dies, or the form is cancelled.
5. Other Important This information needs to be very clear and precise. For example, if transferring include name,
Information address and telephone number of destination and next of kin. Ceilings of treatment include where ACP
is kept. Preferred place of care should be noted.
Tear off slip Complete details and place in “message in a bottle” if available with location clearly stated. For
example, „In the nursing notes in the top drawer of the sideboard in the dining room.‟

• For further information regarding EoLC, ordering new DNACPR forms, for the policy or for the electronic form access:
http://www.southofengland.nhs.uk/what-we-do/end-of-life-care/central-area-documents