This DNACPR decision applies only to CPR treatment where the
child, young person or adult is in cardiopulmonary arrest
In this individual, CPR need not be initiated and the hospital cardiac arrest team or
paramedic ambulance need not be summoned
The individual must continue to be assessed and managed for any care intended
for their health and comfort- this may include an unexpected and reversible crisis
for which emergency treatment is appropriate
All details must be clearly documented in the notes
NHS no: 123 456 780
Address: 5 Ceilidh Side, Loch Gairloch
Date of birth: 01 Jan 1940
Postcode: GA25 3PQ
Hospital no: 012345X
GP and practice: Dr Lochinver, Ullapool
If an arrest is anticipated in the current circumstances and CPR is not to start, tick at least one of these reasons:
 There is no realistic chance that CPR could be successful due to: 1) Coronary heart disease, ........................
2) Advanced heart failure (ejection fraction 25%), 3) COPD .....................................................................
 CPR could succeed, but the individual with capacity for deciding about CPR is refusing consent
CPR could succeed but the individual, who now does not have capacity for deciding about CPR,
has a valid and applicable ADRT or court order refusing CPR
This decision was made with the person who has parental responsibility for the child or young person
This decision was made following the Best Interests process of the Mental Capacity Act
Junior doctor (must have full GMC licence to
practise, and have discussed & agreed with the senior
responsible clinician below before activating DNACPR)
Senior responsible clinician
(If a junior
doctor has signed, the senior responsible doctor or
nurse must sign this at the next available opportunity)
Sign:
Angus Trossachs
Sign:
S. Achmelvich
N
YES NO n/a Has there been a team discussion about CPR in this child, young person or adult?
YES NO n/a Has the young person or adult been involved in discussions about the CPR decision?
YES NO n/a Has the individual’s personal welfare lasting power of attorney (also known as a
health and welfare LPA), court appointed deputy or IMCA been involved in this decision?
YES NO n/a Has the individual agreed for the decision to be discussed with the parent, partner or relatives?
YES NO n/a Is there an emergency health care plan (EHCP) in place for this individual?
Name: Angus Trossachs
Date: 26 Aug 12
Name: Stuart Achmelvich
Status: Consultant
Date: 27 Aug 12
Key people involved in this decision eg. parent, LPA:
Patient, Malcolm(husband), Angus Trossachs, Stuart Achmelvich
For those individuals transferring to their preferred place of care (NB. Cat. 1 transport is usual)
If the individual has a cardiopulmonary arrest during the journey, DNACPR and take the patient to:
The original destination  Journey start
A&E
Try to contact the following key person:
Name: Dr Trossachs
Status: ST2
Tel: 0123 456 7890
If the young person or adult is not aware of the DNACPR, consider informing them as part of their end of life
care discussions. Ask if they wish the parent, partner or relative to know about the DNACPR decision.
Review dates
Date of next review Write name & sign when confirmed
Review whenever the condition or place of care changes
Review dates must be no longer than
15 Sep 12
3 months (never write ‘indefinite’)
Check for any change in clinical status that may
mean cancelling the DNACPR.
Reassess the decision regularly- while this does not
mean burdening the individual and family with a
decision every day, it does require staff to be
sensitive in picking up any change of views during
discussions with the individual, partner or family.
Any senior responsible clinician can review
the DNACPR decision
DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION (DNACPR) v15
Name: Maire Sammhradh
Keep original
in patient’s
care setting
This EHCP contains information to help communication in an emergency for the
individual, to ensure timely access to the right treatment and specialists
This form does not replace a DNACPR form, advance statement or ADRT
North East
Copies of this document cannot be guaranteed to indicate current advicethe original document must be used
Name of individual: Maire Sammhradh
NHS no: 123 456 780
Address: 5 Ceilidh Side, Loch Gairloch
Date of birth: 01 Jan 1940
Postcode: GA25 3PQ
Hospital no: 012345X
Next of kin 1: Malcolm
Phone: 0123 456 789
Relationship: Husband
Next of kin 2: Lyra Scott
Phone: 0123 456 789
Relationship: Daughter
For children and young people, who has parental responsibility? n/a
Lead nurse: Myra Torridon
Place of work: Inverness Hospital
Tel: 0456 789 1234
Lead consultant: Stuart Achmelvich
Place of work: Inverness Hospital
Tel: 0456 789 1234
Emergency out of hours
Person
or service
Other key professionals:
Angus Trossachs
Tel: 0456 789 1234
Cardiology
Tel: 0456 789 1234
Place of work:
Tel:
Place of work:
Tel:
Place of work:
Tel:
Underlying diagnosis(es):
1) Coronary artery disease
2) Advanced heart failure (ejection fraction 25%)
3) COPD
For children: wt
in kg
N
Place of work: Inverness Hospital
Date
Key treatments and concerns you need to know about in an emergency
(eg. main drugs, oxygen, ventilation, active medical issues)
Simvastatin
GTN prn
40mg
od,
verapamil
40mg
tds,
losartan
50mg
daily;
furosemide
40mg
od,
Oxygen 24% as needed
EMERGENCY HEALTH CARE PLAN (EHCP) v12a
GP and practice details: Dr Lochinver, Ullapool. Tel: 0789 456 1234
House bound but able to get around ground floor of house.
Important information for healthcare professionals (if necessary use p3 for additional information)
Has ADRT and DNACPR refusing CPR in the event of cardiac arrest, but would want treatment for
treatable conditions such as exacerbation of COPD. She has had two exacerbations of COPD in the
last 6 months and recovered, but the last episode required an ICU admission.
Would like to spend as much time as possible at home, but has no preference for place of death
Page 1
What to do
Exacerbation of
COPD
Give antibiotics, including hospitalisation for IV
antibiotics.
If respiratory failure, treat with palliative care and
individualised end of life care drugs
Severe angina
Treat with analgesics.
Exacerbation of heart
failure
Keep at home if possible
Treat with IV furosemide- consider SC infusion of
furosemide (80mg/24hrs)
- if no improvement manage with palliative care and
individualised end of life care drugs
Cardiac arrest
See DNACPR
N
If a DNACPR decision has been agreed,
complete the regional DNACPR document
Background information about these decisions
YES NO Does the individual have the capacity to make these care decisions?
YES NO n/a Has there been a team discussion about treatment in this individual?
YES NO n/a Has the individual been informed of the decision?
YES NO n/a Has the individual agreed for the decision to be discussed with the parent, partner or relatives?
YES NO n/a Has this individual made a verbal or written advance statement?
For children:
YES NO n/a Have those with parental responsibility been involved in the decision?
EMERGENCY HEALTH CARE PLAN (EHCP) v12a
Anticipated
emergency(ies)
For those aged 18yrs and over
YES NO n/a Has their Personal Welfare Lasting Power of Attorney, court appointee or IMCA been informed of this EHCP?
YES NO n/a Has an Advance Decision to Refuse Treatment been written by this individual?
Individuals involved in these decisions:
Patient, Malcolm(husband), Angus Trossachs, Stuart Achmelvich
Doctor or nurse (obligatory)
Responsible senior
clinician’s signature: S. Achmelvich
Name of individual: Maire Sammhradh
Name: Stuart Achmelvich
Date: 28 Aug 2012
Status: Consultant
NHS no: 123 456 780
Page 2
Additional information
If required, please use this page to write any additional information
that will inform the clinical team
Maire understands that her medical conditions are advanced and together mean that her
prognosis is limited. She is open about her situation and has made plans for her funeral.
If treatment can result in an improvement that allows her to return home she would accept
this, but draws the line at ICU admission or ventilation. In this situation she understands
that palliative care can keep her comfortable in her last days.
EMERGENCY HEALTH CARE PLAN (EHCP) v12a
N
Page 3
Name of individual: Maire Sammhradh
NHS no: 123 456 780
Advance decision to refuse treatment
(ADRT)
v7 (Adapted from Advance Decisions to Refuse Treatment: a Guide for Health and Social Care Staff, 2008)
My name
Maire Sammhradh
If I became unconscious, these are
distinguishing features that could identify me:
Large mole on my left upper arm
Address
5 Ceilidh Side,
Loch Gairloch,
Date of birth: 01 Jan 1940
NHS no (if known): 123 456 789
Hospital no (if known): 012345X
GA25 3PQ
Telephone Number 0123 456 789
What is this document for?
This advance decision to refuse treatment has been written by me to specify in advance which treatments I don’t
want in the future.
These are my decisions about my healthcare, in the event that I have lost mental capacity and cannot consent
to or refuse treatment.
This advance decision replaces any previous decision I have made.
Advice to the carer reading this document:
Please check
Please do not assume that I have lost mental capacity before any actions are taken.
I might need help and time to communicate when the time comes to need to make a decision.
If I have lost mental capacity for a particular decision check that my advance decision is valid, and
applicable to the circumstances that exist at the time.
If the professionals are satisfied that this advance decision is valid and applicable this decision
becomes legally binding and must be followed, including checking that it is has not been varied or
revoked by me either verbally or in writing since it was made.
Please share this information with people who are involved in my treatment and need to know about it.
Please also check if I have made an advance statement about my preferences, wishes, beliefs, values and
feeling that might be relevant to this advance decision.
This advance decision does not refuse the offer or provision of
basic care, support and comfort
Page 2 (of 4)
Important note to the person making this advance decision:
If you wish to refuse a treatment that is (or may be) life-sustaining you must state in the boxes
“I am refusing this treatment even if my life is at risk as a result.”
Any advance decision that states that you are refusing life-sustaining treatment
must be signed and witnessed on page 3.
My name
Maire Sammhradh
My advance decision to refuse treatment
I wish to refuse the following specific treatments:
In these circumstances:
Ventilation requiring admission to intensive
care
Respiratory failure due to untreatable lung
infection
I am refusing this treatment even if my life is
at risk as a result
Renal dialysis
Renal failure secondary to treatment with
diuretics
I am refusing this treatment even if my life is
at risk as a result
Cardiopulmonary resuscitation
I am refusing this treatment even if my life is
at risk as a result
Artificial hydration and feeding
Myocardial infarction (heart attack)
Severe heart failure
Respiratory failure
Irreversible brain damage
Multi-organ failure
I am refusing this treatment even if my life is
at risk as a result
Page 2 (of 4)
My signature (or nominated person)
Date of signature
Maire Sammhradh
1st September 2012
Witness:
Witness
signature
Address
of witness
Maclom Sammhradh
Name Maclom
of witness
Sammhradh
(husband)
Telephone
of witness s/a
Date 1/9/12
Same address
Person to be contacted to discuss my wishes:
Name Malcolm Sammhradh
Relationship Husband
Address s/a
Telephone same
I have discussed this with (eg. name of healthcare professional)
Profession / Job title: My consultant, Dr. Achmelvich
Date: 1st Sept 12
Contact details: Inverness Hospital, Tel: 0456 789 1234
I give permission for this document to be discussed with my relatives / carers
Yes
No
(please circle one)
My general practitioner is:
Name: Dr. Lochinver
Telephone: 0789 456 1234
Address: The Surgery, Ullapool
Optional review
Comment
Signature of person
named on page 1:
Date/time:
Witness
signature:
Page 3 (of 4)
The following list identifies which people have a copy and have been told about this
advance decision to refuse treatment (ADRT)
Name
Relationships
Telephone number
Myra Torridon
Hospital nurse
0456 789 1234
Angus Trossachs
Hospital doctor
0456 789 1234
Nina O'Sullibhan
Macmillan nurse
0789 123 456
Lyra Scott
Daughter
0123 456 789
Further information (optional)
I have written the following information that is important to me.
It describes my hopes, fears and expectations of life and any potential health and social care problems.
It does not directly affect my advance decision to refuse treatment, but the reader may find it useful, for
example to inform any clinical assessment if it becomes necessary to decide what is in my best interests.
I understand that my heart and chest problems will shorten my life and have discussed what
will happen with my family, doctors and nurses. This is not to say that I want to die now,
because I still enjoy being with my family, my music and watching Coronation Street on the
box. So if treatment is possible and can get me back home I would agree to this, but I do not
wish to be kept alive when I cannot recover fully or if I have developed brain damage that
cannot get better. I would then wish to be allowed to die peacefully with whatever drugs and
care are needed to keep me comfortable.
Page 4 (of 4)