Decisions about treatment

Let's talk: advance care planning

During your time in hospital, we talk to you about your condition and treatment options. It’s important that we decide the right plan together.

You also need to think about what would happen if you could no longer tell us what you want. If you become very unwell, you might not be able to make these decisions.

We can support you to think about what you might want if you become very unwell. We then know how you would like to be cared for. This could include treatments that you would want, or would not want, if your condition gets worse.

This short film talks about decision-making and planning treatment. Most people respond well to treatment, but it is important to think about what you might want if you were to become very unwell. Your healthcare team are responsible for assessing your health. We need to know what is acceptable and what you might want, so that we can make the right plan together.

It is a good idea to communicate your wishes and preferences about your treatment, such as who to involve in discussions, the types of treatment you like to have and a place you prefer to be cared for, so that these can be considered when planning your care.

It's always assumed that people can make decisions about their care, unless there are concerns about their ability to do so. We assess this in 4 ways. So we would look at: if the person understands what's been said, we would look at their ability to remember what's been said, to weigh up the pros and cons, and to tell us how they feel.

You can refuse any treatment that's offered to you if you have the capacity to do so. Also, if you've made an advance decision to refuse treatment, we will respect that too. lf you have made an advance decision, you must show that to your care team so they know what you want.

Decisions on treatment are based on science and evidence. Because of that, you won't be offered any treatment that won't work for you. However, if you disagree with any plan that your team has suggested, you can request a second opinion.

All plans are reviewed regularly with the patient or those close to them. If you are too unwell to participate in that discussion, we will have that chat with the person you have nominated. Alternatively, if you don’t want us to talk about your care with anyone, we will respect that too.

Please talk to your healthcare team if you would like more information.

How we plan and decide your treatment

Your healthcare team is responsible for:

assessing your health
recommending the most suitable treatment options for you

We hope that these treatments help you to feel better.

You can say yes or no to a treatment that we offer you. However, we do not give you any treatments that we know will not help or may harm you. This could include cardiopulmonary resuscitation (CPR). CPR is when we try to start someone's heart and breathing again if they have stopped unexpectedly.

If a treatment does not work or becomes a burden, we may stop it. We always talk to you about this.

If your condition gets worse

Sometimes, despite our best efforts, treatments do not give the results that we hope for and a person's recovery might be uncertain.

This short film talks more about what we might do if someone is seriously unwell and we're not sure if they will get better. This is called uncertain recovery.

This short film talks about planning ahead and what we might do if someone is seriously unwell and we are not sure if they will get better in spite of treatment. We call this uncertain recovery.

There are times when we may give a treatment to a person and we don't know if it will work. This may happen when a person has been living with an illness or a condition for a while and then get something sudden, like an infection. The person may be so sick that they could die, but they could also respond to the treatment.

All treatments are regularly monitored and reviewed and if it becomes clear that a treatment isn't working or that it's a burden for a person, then it might be stopped.

If you are facing uncertain recovery, it's really important to think about how and where you would like to be cared for and to share this with those close to you and the healthcare team. If you want more information, please ask those looking after you.

Please talk to your healthcare team if you would like more information.

If your condition gets worse and you are in hospital, we give you extra support. This is called the AMBER care bundle. We:

monitor you closely
update you about any changes to your condition or treatment
talk to you about your treatment options
update your family, carers or friends, with your permission

We may need to think about many different types of treatments. These could include surgery, medicines, intensive care and even cardiopulmonary resuscitation (CPR).

Who makes decisions if you cannot

It's important that we understand your wishes if you become very unwell and cannot make decisions about your care or treatment. This is called capacity. If you lose your capacity to make these decisions, we speak with the people closest to you about this.

Lasting power of attorney

A lasting power of attorney allows you to give someone that you trust the legal power to make decisions on your behalf. This document only takes effect if you later become unable to make decisions for yourself.

Please tell us if you have signed a lasting power of attorney for health and welfare. The people that you have chosen (your attorneys) can then be involved in decisions about your care.

Your attorneys can refuse treatment on your behalf. However, they cannot make us give you treatment that we believe is not in your best interest.

Best interest decisions

If you cannot make decisions for yourself and do not have a lasting power of attorney, we will make decisions in your best interest. We include you (if possible) and people closest to you when deciding your best interests.

We do not make best interest decisions if the Court of Protection has appointed a deputy for you. A deputy is someone authorised to make decisions on your behalf. Your deputy decides about your healthcare.

Important

If you have an advance decision to refuse treatment, we will use this to make decisions about any treatments specified in the document.

We make decisions in your best interest about any other treatments not included in the document.

Recording your wishes about treatment

We use an advance statement to record how you want to be cared for. This document can include anything that's important to you about your future health. For example, you can write down treatments that you would prefer to have or would rather not have.

An advance statement is not legally binding, but it can help us to follow your wishes. We use the document to make decisions that are right for you. This is important if you cannot make these decisions yourself.

The advance statement should be attached to your medical notes. This means that the people involved in your care can find the document easily.

An advance decision to refuse treatment lets you write down specific treatments that you do not want to have in the future. This document is used when you cannot make or communicate decisions for yourself.

Advance decisions are legally binding in England and Wales. Healthcare professionals must follow your wishes, provided that the advance decision meets certain requirements.

Talking about resuscitation

Cardiopulmonary resuscitation (CPR) is a treatment that can be given when you stop breathing or your heart stops beating. The aim of CPR is to try to start your breathing and heart again.

In hospital, about 2 in 10 people survive and leave hospital after having CPR. Survival rates are usually lower in other places.

Why CPR is not always suitable

CPR works best for people who were reasonably healthy before. However, from a medical point of view, it's unlikely to help people who are frail or who have been in poor health for a long time.

It's important to understand that CPR is an invasive procedure. CPR often causes broken ribs or damage to the organs inside your body.

CPR is not likely to be successful for people naturally approaching the end of their life. It could prevent a peaceful and dignified death.

If successful, CPR rarely returns people to their previous quality of life.

Cardiopulmonary resuscitation, usually called CPR, is a treatment used to try and restart somebody's heart when it stops unexpectedly. It's a treatment that involves pushing blood around the body by giving chest compressions, which involve pushing very hard on the centre of the chest, blowing air into the lungs with a special bag, usually via a tube that's inserted into the airway, and sometimes we will also give drugs, which are given either through a vein or sometimes using a special needle put into the bone, and electricity to try and get the heart restarted. CPR works best in people who were relatively well before their heart stopped. It doesn't work very well in people who are very frail or who have a lot of underlying medical problems, which make it unlikely that we can resuscitate them successfully.

Because it can cause pain, discomfort and distress, it's important to identify those who won't benefit from the CPR to protect them from receiving it. CPR is not a treatment for ordinary peaceful dying.

CPR is something that you can talk to us about at any time and we will always talk to you about it if there are concerns as to whether it is an appropriate treatment for you. If you disagree with any decision that's made, you can request a second opinion.

It's possible that you won't be able to discuss your wishes and beliefs about CPR with the medical team because you're too unwell. If that happens, the medical team will talk to those who are important to you about it. That means it's very important that you have talked to your family and friends about your wishes and beliefs, so that the medical team can gather as much relevant information as they can before they make their decision.

If you've made an advance decision to refuse treatment, a living will, that applies to CPR, you must tell the team looking after you. If you've appointed a lasting power of attorney for health, this person can refuse CPR on your behalf but they can't request it if we think that it might fail.

When CPR is not going to be given, the doctors looking after you will fill in a form. This is called a 'do not attempt cardiopulmonary resuscitation' order, or a DNACPR order. This is a communication tool that informs everyone who's looking after you that we're not going to give that treatment. If you are going home, they will give you a copy of the form to keep at home. It's very important that healthcare providers who are coming into your home to give treatment are aware of that order.

DNACPR applies to CPR only. You can still come into hospital and receive all other forms of treatment. Please talk to your healthcare team for more information.

Deciding not to have CPR

You can choose to refuse CPR in advance. Please tell your doctor or healthcare team at any time if you decide this.

We complete a DNACPR form. This stands for do not attempt cardiopulmonary resuscitation. It can also be called DNAR (do not attempt resuscitation) or DNR (do not resuscitate). They all mean the same thing.

DNR, DNAR and DNACPR decisions are about CPR only. You get all the other treatments that you need.

We write the DNACPR in your healthcare record and give you a paper copy that you can take home with you.

You can make the decision legally binding by writing an advance decision to refuse treatment. This document explains to a doctor or healthcare team when you want to refuse CPR. You can also use the document for other treatments.

If you want to change your decision about refusing CPR, tell your doctor or healthcare team.

If we believe that CPR is not suitable

Sometimes, we might decide that a person should not have CPR. We only do this if we believe that CPR will not work or is not in the person's best interests.

If we believe that CPR is not suitable, we will fill in a DNACPR form. We tell you if we have completed a DNACPR form or plan to do this. We explain why we think that this is the right decision and give you the chance to talk about it with us.

A healthcare professional can legally decide not to offer CPR because they believe it will not work. They do not need to get that person's or their family's permission. We understand that this might feel difficult, even if you agree with the decision but especially if you do not.

We appreciate that you may have strong views and beliefs about CPR. We want to reassure you that if we complete a DNACPR form, it's because we believe that CPR will not work or would cause more harm than good. The decision is always made on an individual basis and we think about what you would prefer.

We always recommend talking to your healthcare team about why they have made a DNACPR decision. If you do not agree with the decision, you can ask for a second opinion.

Information and support about DNACPR decisions

We understand that it can feel emotional and challenging to think about DNACPR decisions for yourself or a loved one. Please talk to someone in your healthcare team. They can answer questions if you're unsure about anything and help to reassure you.

The NHS website has information about:

the success rate of CPR
how DNACPR decisions are made and recorded
what happens if you cannot make a decision about CPR for yourself in advance
what to do if you are concerned about a DNACPR form in your medical record or someone else's record

Emotional and spiritual support

We support people of all faiths and beliefs or who would like to talk to someone.

Our spiritual care team is happy to meet with you, family members or friends. We're available 24 hours a day, 7 days a week.

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Resource number: 5332/VER2
Last reviewed: December 2024
Next review: December 2027

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