DNAR and Advance Care Planning

Clinical Scenario

Frank Hartley, 74, a retired builder, attends for a COPD review. He has severe COPD with FEV1 25% predicted, has been hospitalised three times in the past year with exacerbations, and is now on long-term oxygen therapy. His respiratory consultant has written to you suggesting that advance care planning and a DNAR discussion would be appropriate. Frank is aware his condition is worsening but has not previously discussed end-of-life preferences. His wife Jean accompanies him and becomes distressed when the topic is raised. Frank himself is pragmatic and wants honest information.

What This Case Tests

Initiating an advance care planning conversation sensitively; explaining what DNAR means and what it does not mean; differentiating DNAR from withdrawal of treatment; managing the different emotional responses of the patient and their spouse; documenting advance care planning decisions correctly; understanding Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process

Common Mistakes Trainees Make

The three most common mistakes are: avoiding the conversation entirely because it feels uncomfortable or because the spouse is distressed — the consultant has identified this as clinically appropriate and delay serves no one; conflating DNAR with giving up or withdrawing treatment, which is the most common patient and family misunderstanding and must be addressed explicitly; and focusing so heavily on the DNAR form that you miss the broader advance care planning conversation about preferences for place of care, what matters to the patient, and escalation decisions.

The Consultation Challenge

Frank is pragmatic and wants honesty. Jean is frightened. You need to manage both emotional registers simultaneously while having a clinically important conversation.

Do not ambush them with the DNAR discussion. Frame it as part of good COPD care: 'Frank, as part of looking after your COPD properly, there is something your consultant and I think it would be helpful to discuss — your preferences for future care, especially if you become more unwell. This is not because anything has changed suddenly — it is because planning ahead when you are well enough to make decisions puts you in control.'

Check his understanding of his condition: 'How do you feel things have been going with your breathing over the past year?' He knows he is deteriorating. Meet him where he is rather than delivering information he already has.

Introduce advance care planning before DNAR: 'Advance care planning is about making sure that if you become too unwell to speak for yourself, the people looking after you know what you would want. It covers things like: where you would prefer to be cared for if you became very ill, what matters most to you, and what treatments you would or would not want.' This broader framing makes the subsequent DNAR conversation less stark.

Explain DNAR clearly: 'One specific decision we should discuss is about CPR — cardiopulmonary resuscitation. If your heart were to stop, CPR involves chest compressions and potentially electric shocks to try to restart it. I want to be honest with you — in someone with severe COPD like yours, CPR is very unlikely to be successful, and if it did restart the heart, the outcome would very likely involve intensive care and a poor quality of life afterwards. A DNAR decision means that if your heart stops, we would keep you comfortable rather than attempting resuscitation. It does not mean we stop treating you — you would still receive antibiotics, oxygen, steroids, and everything else that helps.'

Address Jean's distress directly: 'Jean, I can see this is upsetting, and that is completely normal. Talking about these things is hard. But having this conversation now, when Frank can tell us what he wants, is actually a gift — it means that if a crisis happens, you will not be left guessing.'

Ask Frank what matters to him: preferred place of care (home vs hospital), whether he would want to go to intensive care, who he would want to make decisions if he could not. Document his responses on the ReSPECT form.

Time check: Minutes 1-3 on framing the conversation and checking his understanding of his COPD trajectory. Minutes 3-6 on advance care planning discussion — preferences, values, what matters. Minutes 6-9 on DNAR explanation with honest prognostic information. Final 3 minutes on documenting decisions, supporting Jean, and follow-up.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you establish the patient's understanding of their condition and prognosis before introducing advance care planning. They look for exploration of the patient's values, preferences, and priorities — what matters to Frank, not just what treatment decisions need making. Checking whether he has a lasting power of attorney for health and welfare demonstrates system knowledge.

Clinical Management and Medical Complexity: Examiners evaluate whether you explain DNAR accurately, including the distinction from withdrawal of treatment, and provide honest prognostic information about CPR outcomes in severe COPD. Knowledge of the ReSPECT process, documentation requirements, and how the decision is communicated across settings (ambulance, hospital, community) shows practical understanding. Discussing the broader advance care plan — preferred place of care, escalation preferences — goes beyond the DNAR form.

Relating to Others: This is the most heavily weighted domain. Examiners look for sensitivity in initiating the conversation, honest but gentle communication of prognostic information, and skilful management of both Frank's pragmatism and Jean's distress. The ability to explain DNAR as an act of care rather than abandonment is the key communication challenge. Both Frank and Jean should leave feeling heard, informed, and supported.

Example Opening

Strong opening: "Hello Frank, hello Jean. Before we do the usual COPD checks, there is something your consultant and I have been discussing that I think would be really helpful to talk about today — your preferences for future care. This is not because anything has changed suddenly, but because planning ahead puts you in control."

When explaining DNAR: "A DNAR decision does not mean we stop treating you. You will still get antibiotics, oxygen, steroids — everything that helps. What it means is that if your heart were to stop, we would keep you comfortable rather than attempting CPR, which in your situation is very unlikely to work and could cause significant distress."

Avoid: "We need to talk about what happens when things get worse" — this is too blunt an opening and will immediately distress Jean. Frame it as planning and empowerment, not decline.

How This Appears in the SCA

DNAR and advance care planning discussions test your ability to have honest end-of-life conversations, explain resuscitation decisions without euphemism, and manage different emotional responses within a family. Examiners value candidates who are clear, compassionate, and who address the broader advance care planning context rather than focusing narrowly on the DNAR form.

Key Statistic

The survival rate from out-of-hospital cardiac arrest in patients with severe chronic illness is less than 2%. In patients with severe COPD requiring long-term oxygen therapy, successful CPR leading to meaningful recovery is extremely rare.

Relevant Guidelines

• NICE NG31: Care of dying adults in the last days of life
• NICE QS13: End of life care for adults
• ReSPECT process guidance
• BMA/Resuscitation Council guidance on DNAR decisions
• NICE NG115: Chronic obstructive pulmonary disease (acute exacerbation management).

Frequently Asked Questions

What is the difference between DNAR and withdrawing treatment?

DNAR means that if the patient's heart stops, CPR will not be attempted. It does not affect any other treatment. The patient continues to receive all appropriate active treatment — antibiotics, oxygen, pain relief, IV fluids, hospital admission if beneficial. Many patients and families conflate DNAR with 'giving up,' and addressing this misunderstanding directly is one of the most important parts of the conversation. Use clear language: 'A DNAR decision only applies to the specific situation where your heart stops. Everything else we do for you continues exactly as before.'

What is the ReSPECT process?

ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) is a process that creates a summary of personalised recommendations for clinical care in a future emergency where the patient cannot make or express choices. It covers more than just CPR — it includes preferences for treatment escalation, place of care, and what matters to the patient. The ReSPECT form is completed collaboratively with the patient and travels with them across care settings. It replaces the older DNAR form in many NHS trusts. Demonstrating knowledge of ReSPECT in the SCA shows current awareness.

How do I manage a distressed family member during a DNAR discussion?

Acknowledge the distress directly: 'Jean, I can see this is really upsetting, and that is completely understandable.' Explain why the conversation is happening: 'Having this conversation now, when Frank is well enough to tell us what he wants, is actually an act of love — it means you will never be left guessing about his wishes in a crisis.' Give the family member permission to step out briefly if needed. Focus on what continues rather than what stops: emphasise ongoing active treatment, comfort, and support. Offer a follow-up conversation once the initial shock has settled.

Can a patient refuse a DNAR recommendation?

A DNAR decision is a clinical recommendation, not a consent form. However, the patient's views must be central to the discussion. If Frank wanted full resuscitation despite the poor prognosis, you should explain honestly that CPR is very unlikely to succeed and could cause suffering, but ultimately document his expressed wish and ensure it is communicated. In practice, most patients accept a DNAR recommendation when the rationale is explained clearly and compassionately. If there is disagreement, involve the palliative care team or a second senior clinician to support the conversation.

How do I document advance care planning decisions?

Document on the ReSPECT form or equivalent local form. Include: date and time of discussion, who was present, the patient's understanding of their condition, their expressed preferences for future care (preferred place, escalation preferences, DNAR decision), and confirmation that the patient had capacity at the time of the discussion. Ensure the form is accessible — in the patient's home (often kept in a specific location like the fridge), on the GP record, shared with the ambulance service and hospital, and available to out-of-hours services. Advance care planning is only useful if it is accessible when needed.