Intended for healthcare professionals

Rapid response to:


Integrated care scheme for older people will roll out across England

BMJ 2015; 350 doi: (Published 23 April 2015) Cite this as: BMJ 2015;350:h2157

Rapid Response:

The piece in the Daily Mail is confused

Further to the comment by Dr Anand (this series of rapid responses), I have read both the piece in today's Daily Mail and also NHS England's end-of-life advice. It seems (BBC Radio 4 this morning) that NHS England says it has not issued any recent instruction about this issue.

The Mail has got the NHS England advice wrong - what the advice points out, is essentially that unless patients are actually asked, you do not know whether they would refuse attempted cardiopulmonary resuscitation while it might still be clinically 'successful'.

More significantly, the Mail confuses the things the NHS usually refers to as 'a DNACPR Form/Order' (something signed only by clinicians) with a written Advance Decision refusing CPR (signed by the patient and a witness, but not necessarily signed by any clinician).

Whereas the Advance Decision is in legal terms a 'binding decision originating from the patient' (a formal refusal of consent to CPR), most 'DNACPR Orders' are simply a clinical opinion, that attempted CPR would be unsuccessful. So the Mail's suggestion that patients are being asked to agree to DNACPR Orders, is at best 'muddled': if patients decide to refuse CPR they should create a written ADRT [and get their doctor to sign something confirming the doctor has read - not 'agreed to', but read - it]. I am not quite sure, what the [legal] point of 'agreeing to a DNACPR signed by your doctor' is: you might as the patient also believe that CPR would fail, and you might also wish to prevent attempted CPR, but the Advance Decision 'carries the patient's legal authority' whereas the 'DNACPR Order' is merely a clinical opinion (extended a little, via section 42 of the Mental Capacity Act, perhaps, in the sense that section 42 'sort of allows senior clinicians to guide junior clinicians' {section 42, is very complicated in terms of what it leads to} - but NOT 'a legal order').

Competing interests: No competing interests

27 April 2015
Michael H Stone
Retired Non Clinical
Coventry CV2 4HN