Goals of care, treatment escalation, emergency planning and CPR

Goals-of-care discussions should connect the person's priorities with what medicine can realistically achieve. The conversation asks which outcomes matter, what burdens are acceptable, which treatments are clinically appropriate and what should happen in an emergency. The product should be a positive care plan, not only a list of interventions that will not be offered.

This prevents therapeutic abandonment. A decision not to offer ICU admission may coexist with active treatment of infection, oxygen where appropriate, symptom control, ward-based treatment, communication and review. The precise plan depends on the clinical situation and the person's goals.

A DNACPR decision addresses whether cardiopulmonary resuscitation should be attempted if cardiorespiratory arrest occurs. It does not itself mean no antibiotics, no hospital transfer, no investigations, no fluids or "comfort care only". The current Welsh national policy states explicitly that DNACPR decisions refer only to CPR and do not alter other aspects of optimal care and treatment.

Because CPR is a treatment, discussions should be clinically realistic. Patients have the right to refuse CPR, but there is no requirement to offer a treatment that will not work or is not clinically appropriate. Communication remains essential, and disagreement should be handled sensitively rather than through unexplained form completion.

ReSPECT supports person-centred conversations about what matters and what treatments are realistic in a future emergency when the person may not be able to communicate. It records personalised clinical recommendations. The 2025 Resuscitation Council UK ethics guideline emphasises broader emergency and future-care planning, documentation of the rationale for recommendations, accessibility across settings and review when circumstances change.

Clinical recommendations in an emergency plan are not themselves legally binding. A separate legally binding document, where valid and applicable under national law, may constrain treatment decisions. ReSPECT should therefore never be taught as a universal advance-refusal form or consent form.

ReSPECT is not uniformly implemented across the UK. The Resuscitation Council UK adoption page, last updated May 2026, says many parts of England and Scotland have adopted it, Wales has not adopted it, and Northern Ireland is working towards national adoption in 2026. A separate March 2026 policy briefing refers to full rollout across Northern Ireland in 2026. Because these official sources describe an evolving position, local implementation must be checked immediately before publication and in practice.

Wales currently uses the national Sharing and Involving DNACPR policy and its own future-care planning arrangements. Learners should avoid assuming that a form used in one region has the same operational role elsewhere.

Emergency recommendations should be reviewed when the person's wishes, health or clinical circumstances change. The 2025 RCUK ethics guideline recommends steps such as second opinion, clinical ethics advice and/or legal advice when shared agreement cannot be reached. Clear documentation should show the rationale, the person's values, relevant prognosis and the expected benefit or burden of CPR or other emergency treatments.

Families should be listened to and supported, but they do not acquire a right to demand clinically inappropriate CPR simply by objecting to a recommendation. Equally, clinicians should not hide decisions behind jargon or forms. Good practice combines transparent clinical reasoning with respectful communication.

| Myth | Reality |

| --- | --- |

| "DNACPR means no treatment" | It relates to CPR if cardiorespiratory arrest occurs. |

| "A DNACPR decision automatically prevents hospital transfer" | Transfer and other treatments need their own clinical decisions. |

| "Family consent is always required for a clinical DNACPR recommendation" | Families may need involvement/consultation, but legal and clinical roles depend on capacity, authority and jurisdiction. |

| "A ReSPECT plan is a legally binding refusal" | It records emergency clinical recommendations; legally binding documents are separate. |

| Nation | Official RCUK position reviewed 19 Sep 2026 |

| --- | --- |

| England | Many areas adopted; regional variation remains. |

| Scotland | Several boards adopted; variation remains. |

| Wales | No national adoption on the RCUK adoption page. |

| Northern Ireland | Working towards national adoption in 2026; RCUK policy briefing describes rollout during 2026. |

1. A patient with a DNACPR decision develops treatable sepsis and a junior assumes antibiotics are inconsistent with the plan. DNACPR alone does not mean no treatment.

2. A ReSPECT form from another region is treated as a binding refusal without reviewing current circumstances. It is a clinical recommendation plan and should be interpreted with current context and any separate legal document.

3. A family says CPR must be attempted because they do not agree with the clinician's recommendation that it would not succeed. The disagreement requires explanation and possibly review, not automatic provision of clinically inappropriate CPR.

• Start with goals, values and clinically realistic outcomes.
• Make clear that DNACPR applies to CPR only.
• Record positive treatment recommendations as well as limits.
• Check whether ReSPECT or an alternative emergency plan is locally implemented.
• Identify any separate legally binding refusal or proxy authority.
• Review plans when circumstances change and escalate unresolved disagreement appropriately.