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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- DNACPR (Do Not Attempt CPR) is a clinical decision that CPR will not be attempted because it would not restart the heart, or would not be in the patient's best interests
- Tracey v Cambridge (2014): landmark ruling — there is a PRESUMPTION of involvement. The patient (or family if patient lacks capacity) must be consulted UNLESS discussion would cause serious physical or psychological harm
- A DNACPR decision applies ONLY to CPR — it does NOT mean "do not treat". All other treatment continues unless separately decided
- CPR may not be appropriate: where cardiac arrest is an expected part of dying, where CPR is unlikely to be successful, or where the burdens outweigh the benefits
- ReSPECT forms are replacing standalone DNAR forms in many NHS trusts — broader emergency treatment planning
Overview
A DNACPR decision is a clinical recommendation that cardiopulmonary resuscitation should not be attempted in the event of a cardiac or respiratory arrest. It is NOT a decision to withhold all treatment — this is a critical distinction. The decision should be based on clinical assessment of whether CPR is likely to be successful and whether it would be in the patient's best interests. The Tracey v Cambridge University Hospital NHS Foundation Trust ruling (2014) established that there is a duty to involve the patient in DNACPR discussions unless there is a compelling reason not to. The ReSPECT process provides a more comprehensive framework for emergency treatment decisions including but going beyond CPR.
Epidemiology
Approximately 80% of in-hospital cardiac arrests occur in patients who could have been identified as dying. CPR survival in hospital is approximately 20% overall but much lower in certain subgroups (metastatic cancer: <5%). The Tracey ruling (2014) was a watershed — prior to this, DNACPR decisions were often made without informing patients. Studies since have shown improved patient/family involvement but persistent variation in practice.
Indications
Symptoms
CPR will not restart the heart and breathing (futile) — e.g. expected death from advanced terminal illness
CPR may restart the heart but the patient will not benefit — e.g. severe irreversible brain injury, immediate post-resuscitation quality of life would be unacceptable to the patient
The patient with capacity has made an informed decision to refuse CPR
A valid ADRT refusing CPR exists
An LPA for health and welfare has refused CPR on the patient's behalf (in their best interests)
Signs
DNACPR applies ONLY to CPR. All other treatments continue as clinically appropriate — antibiotics, fluids, oxygen, analgesia, etc.
DNACPR is NOT the same as a decision to withdraw treatment or to provide only palliative care
A DNACPR decision can be made by any senior clinician but should involve the healthcare team
Assessment
First-line
Clinical assessmentAssess prognosis, likelihood of CPR success, patient's overall condition, comorbidities, and functional status
Patient wishesDiscuss with the patient if they have capacity. Explore values, understanding of their condition, and preferences
Second-line
Check for advance decisionsValid ADRT refusing CPR, ReSPECT form, registered LPA for health and welfare
Consult family/carersIf patient lacks capacity — consult those close to the patient about their known wishes, values, and what the patient would want
Specialist
Second opinionIf there is disagreement between clinicians, or between the clinical team and the patient/family
Clinical ethics committeeFor complex or contentious cases
Management
BMA/Resuscitation Council UK/RCP Joint Statement on DNACPR (2023); Tracey v Cambridge (2014)1
Decision-making process
- Senior clinician makes the clinical assessment of whether CPR is appropriate
- Discuss with the patient whenever possible (Tracey ruling: presumption of involvement)
- Exception: discussion may be omitted only if it would cause serious physical or psychological harm to the patient — this must be documented and justified
- If patient lacks capacity: consult those close to the patient about their wishes and values
- Document the decision clearly: clinical reasoning, who was consulted, the patient's/family's response, and the name and grade of the decision-maker
2
Communication
- Explain that DNACPR means only that CPR will not be attempted — all other treatments continue
- Emphasise that the decision is based on the assessment that CPR would not work or would not be in their interest
- Allow time for questions and emotional response
- Offer a second opinion if the patient or family disagrees
3
Review
- DNACPR decisions should be reviewed regularly — especially if the clinical situation changes
- Review on transfer between clinical settings (ward to ward, hospital to community)
- A DNACPR decision can be revoked at any time by the patient (if they have capacity) or by the clinical team
Complications
- Failure to discuss: Making a DNACPR without involving the patient violates Article 8 (private life) — Tracey ruling
- Blanket policies: Applying DNACPR based on age, disability, or diagnosis alone is discriminatory and unlawful (Equality Act 2010)
- Misunderstanding: Patient or family believing DNACPR means "no treatment at all" — must be clearly communicated
- COVID-19 concerns: Reports of inappropriate blanket DNACPR decisions during the pandemic — subject of CQC investigation
UKMLA Exam Tips
- 1DNACPR ≠ do not treat. All other treatments continue. This is the most commonly tested misconception
- 2Tracey ruling: you MUST discuss DNACPR with the patient unless doing so would cause serious harm. There is a PRESUMPTION of consultation
- 3A patient with capacity can REFUSE CPR and this must be respected
- 4Nobody — patient, family, or LPA — can DEMAND CPR if it is clinically futile. Doctors are not obliged to provide futile treatment
- 5DNACPR must be reviewed regularly and on transfer between settings
- 6Making DNACPR decisions based solely on age, disability, or learning disability = discriminatory and unlawful
Put your reading into practice
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Choose UKMLA questions from the existing bank. General exam practice covers your selected topics; it is not filtered to this article. Your usual question-bank access applies.
Choose UKMLA practiceAfter your session, return to this section to revisit the reading and choose your next review.
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