Mastering DNACPR Decisions in MRCP PACES Ethics Stations

Why DNACPR Decisions Are High-Yield for PACES

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are among the most frequently tested ethical and communication scenarios in the MRCP PACES examination. Examiners use this topic because it simultaneously assesses your clinical reasoning, ethical understanding, communication skills, and ability to navigate emotionally charged conversations — all hallmarks of a competent registrar.

As a PACES candidate, you are expected to demonstrate a senior-level approach: one that is legally sound, clinically justified, and compassionately communicated.

The Legal and Ethical Framework You Must Know

The Mental Capacity Act 2005

This is the cornerstone legislation for DNACPR decisions in England and Wales. Key principles include:

• Presumption of capacity: Every adult has the right to make their own decisions unless proven otherwise.

• Best interests: If a patient lacks capacity, all decisions must be made in their best interests, considering their wishes, beliefs, and values.

• Advance decisions: A valid and applicable advance decision to refuse treatment (ADRT) must be respected.

• Lasting Power of Attorney (LPA): A health and welfare LPA can make decisions about life-sustaining treatment if the patient lacks capacity.

The Tracey Judgement (2014)

This landmark Court of Appeal ruling established that there is a presumption in favour of patient involvement in DNACPR decisions. You must:

1. Inform patients (or those close to them) when a DNACPR decision is being considered.

2. Provide clear reasons for the decision.

3. Involve them in the decision-making process.

Exceptions are narrow and include:

• The patient explicitly states they do not wish to be informed.

• The clinician believes disclosure would cause psychological harm.

The Relevant GMC Guidance

• GMC Good Medical Practice (2024): Emphasises patient-centred care, honest communication, and shared decision-making.

• GMC End of Life Care Guidance: Stresses the importance of open, honest conversations about treatment limitations.

• Resuscitation Council UK (2016, updated 2021): Provides the framework for DNACPR decisions, now transitioning to ReSPECT (Recommended Summary Plan for Emergency Care and Treatment).

The ReSPECT Process

The ReSPECT form is replacing traditional DNACPR forms across the NHS. As a PACES candidate, demonstrating awareness of ReSPECT signals up-to-date knowledge. The ReSPECT process involves:

1. Clinical assessment of the patient's overall condition.

2. Shared discussion about goals of care, priorities, and realistic outcomes.

3. Shared agreement on recommendations regarding CPR and other emergency treatments.

4. Documentation of the plan, including whether CPR is recommended or not.

How to Approach a DNACPR Scenario in PACES

Station Structure: What to Expect

DNACPR scenarios typically appear in Station 4 (Communication Skills) or Station 5 (Integrated Clinical Assessment). You may encounter:

• A patient or family member upset about a DNACPR decision already made.

• A clinical scenario where you must initiate a DNACPR conversation.

• A relative requesting CPR for a relative who has a DNACPR in place.

• A patient requesting to discuss their resuscitation status.

Step-by-Step Consultation Framework

Step 1: Setting the Scene

• Introduce yourself clearly and confirm the patient's/relative's identity.

• Set the agenda early: "I'd like to discuss something important about your future care, specifically about a treatment called resuscitation. Is that okay?"

• Check their understanding of the clinical situation first.

Step 2: Assess Their Understanding and Values

Before discussing DNACPR, explore:

• "What do you understand about your current condition?"

• "What is important to you in terms of your care?"

• "Have you ever thought about what you would want if you became seriously unwell?"

This establishes patient-centredness and helps tailor the conversation.

Step 3: Explain CPR Realistically

Use simple, honest language:

• "CPR is a treatment we use when someone's heart stops beating. It involves pressing hard on the chest and may involve electric shocks and breathing support."

• Discuss the realistic success rate in the context of their condition (e.g., for a frail patient with multiple comorbidities, survival to discharge is extremely low — often less than 5%).

• Avoid false hope but remain compassionate: "I want to be honest with you because that's what you deserve."

Step 4: Present the DNACPR Decision

Frame the decision as a clinical recommendation, not a withdrawal of care:

• "Based on everything I know about your condition, I would not recommend CPR if your heart were to stop. This is because CPR would be very unlikely to work and could cause you significant harm. This does not mean we would stop any other treatments — we would continue to provide the best possible care for you."

Step 5: Address Concerns and Emotions

Common reactions and how to handle them:

Step 6: Document and Follow Up

• Confirm the decision is documented appropriately.

• Discuss review dates and circumstances.

• Offer written information.

• Arrange follow-up to revisit the discussion.

Common Pitfalls That Cost Candidates Marks

1. Being Too Directive

Bad: "We've decided you should not be resuscitated."

Better: "I'd like to talk through what CPR would mean for you and share my recommendation. Your views are very important in this."

2. Using Jargon Without Explanation

Avoid terms like "futile," "quality of life," or "palliative" without careful explanation. These can sound dismissive.

3. Failing to Involve the Patient or Family

Post-Tracey, failure to involve patients or those close to them is a serious error that examiners will penalise heavily.

4. Confusing Capacity Issues

If the patient has capacity, they should be involved. If they lack capacity, decisions are made in their best interests involving family, IMCAs (Independent Mental Capacity Advocates) where appropriate, and the clinical team.

5. Not Addressing Emotional Content

PACES examiners assess your ability to acknowledge and respond to emotions. Use phrases like:

• "I can see this is really difficult for you."

• "It's completely understandable to feel this way."

High-Yield Clinical Scenarios for PACES

Scenario 1: Frail Elderly Patient with Pneumonia

A 92-year-old woman with severe frailty, dementia, and pneumonia. The team is considering a DNACPR.

Key points:

• Assess capacity (likely lacks capacity due to dementia/delirium).

• Best interests decision involving family.

• Discuss futility of CPR in this context.

• Emphasise ongoing active treatment.

Scenario 2: Patient with Metastatic Cancer

A 68-year-old man with metastatic lung cancer asks about his resuscitation status.

Key points:

• Open the conversation sensitively.

• Discuss prognosis honestly but compassionately.

• Explore his values and priorities.

• Align with palliative care goals.

Scenario 3: Family Conflict Over DNACPR

A daughter is distressed that her father has a DNACPR in place and demands it be reversed.

Key points:

• Listen actively and validate her emotions.

• Explain the clinical reasoning clearly.

• Clarify that the decision is a clinical one but that her father's wishes are paramount.

• Offer a second opinion if appropriate.

Key Legal Principles Summary Table

Practical Tips for Exam Day

1. Always start with the patient's agenda — what do they understand and want?

2. Use the SPIKES protocol for structuring difficult conversations.

3. Practise the language of DNACPR conversations until it feels natural.

4. Demonstrate awareness of ReSPECT — it shows currency with NHS practice.

5. Show empathy throughout — this is not just about getting the decision right; it is about how you make the person feel.

6. Summarise and confirm understanding before closing.

7. Offer follow-up — these conversations are rarely one-time events.

Conclusion

DNACPR decisions in PACES are less about the decision itself and more about the process, communication, and ethical reasoning you demonstrate. The examiners want to see a candidate who is clinically sound, legally aware, compassionate, and confident in leading a difficult conversation.

Remember: a good DNACPR conversation protects the patient's dignity, respects their autonomy, ensures appropriate clinical care, and supports families through one of the most difficult moments they will face. Master this, and you will demonstrate exactly the kind of registrar-level competence that PACES is designed to assess.

For further reading, refer to the Resuscitation Council UK guidelines, GMC End of Life Care guidance (2024 update), and the Mental Capacity Act 2005 Code of Practice.