This guide covers the sensitive and legally complex topic of End of Life Decisions MSRA scenarios. In the Professional Dilemmas paper, candidates must navigate the rigid hierarchy of decision-making, from Advance Directives down to Best Interests.
End-of-life decision-making aligns clinical judgement with the person’s values, legal instruments, and the Mental Capacity Act (MCA). A DNACPR decision applies only to attempted cardiopulmonary resuscitation; it does not mean “do not treat”. Appropriate treatments such as antibiotics, oxygen, fluids, analgesia and symptom control should usually continue if clinically indicated.
Advance Decisions to Refuse Treatment (ADRT) can be legally binding if valid and applicable. Where they refuse life-sustaining treatment, they must be written, signed, witnessed, and state that they apply even if life is at risk. A registered Health and Welfare Lasting Power of Attorney (LPA) may decide when the person lacks capacity, within the scope of their authority and subject to best interests; they cannot demand clinically inappropriate treatment.
In MSRA SJT questions, high-scoring options show you exploring values early, checking for ADRT/LPA, distinguishing DNACPR from broader treatment decisions, and, when capacity is lacking, following an MCA best-interests process. You are expected to avoid blanket DNACPRs, consult patients and those close to them where practicable, and leave a clear record of who was involved, what was decided, and when it will be reviewed.
1. Explore the patient’s values, fears, priorities, and understanding of their condition before focusing on forms.
2. Check for any ADRT or Health and Welfare LPA, and confirm validity, applicability, and scope where present.
3. Explain realistically what CPR involves and its likely outcomes in this person’s context, emphasising that DNACPR covers CPR only.
4. Involve the patient in DNACPR and wider emergency care planning whenever they have capacity, unless doing so would cause serious harm.
5. If capacity is lacking, follow MCA best interests: consult those close to the person, consider ADRT/LPA, and focus on the person’s values and least restrictive options.
6. Reject blanket or group DNACPR policies (for example “all residents”) and make individual decisions.
7. Ensure that appropriate non-CPR treatments (symptom control, antibiotics, oxygen, fluids) continue or are adjusted according to goals of care.
8. Use local tools such as ReSPECT or equivalent to record emergency care planning, including DNACPR, treatment ceilings, and review triggers.
9. Communicate sensitively and clearly with families and carers, managing disagreements by listening, explaining rationale, and involving seniors when needed.
10. Document discussions, ADRT/LPA checks, decisions made, who was consulted, reasons, and agreed review points.
Trap answers usually involve blanket policies, misuse of DNACPR, ignoring ADRT/LPA, excluding patients and families without justification, or avoiding documentation to sidestep accountability.
* “A DNACPR form covers attempted resuscitation only; you will still receive all other treatments that are appropriate for you.”
* “Do you have anything written down, like an advance decision, or a lasting power of attorney for health decisions?”
* “Because you do not have capacity to decide today, we will look for any ADRT or LPA and then decide in your best interests after speaking with those who know you well.”
* “I will record what we discussed, what was decided about CPR and other treatments, who was involved, and when we will review this plan.”
P = Preferences and values explored early
E = Engage patient and those close to them in decisions
A = ADRT and LPA checks and clarification
C = CPR discussion with realistic outcomes; DNACPR is CPR-only
E = End-of-life goals documented (for example ReSPECT, advance care plan)
P = Plan best-interests pathway if capacity lacking
L = Least restrictive, lawful decisions under MCA
A = Act against blanket DNACPR and undertreatment
N = Notes: clear record of who, what, why, and review
Does DNACPR mean no active treatment at all?
No. DNACPR relates only to attempted CPR. Other appropriate treatments, including antibiotics, fluids, oxygen, escalation within agreed limits, and full symptom control, should still be considered and offered if clinically appropriate.
When is an ADRT legally binding?
An ADRT must be valid (not withdrawn or overridden, capacity at the time, consistent with later decisions) and applicable to the current situation. If it refuses life-sustaining treatment, it must be in writing, signed and witnessed, and state that it applies even if life is at risk.
What is the role of a Health and Welfare LPA?
A registered Health and Welfare LPA can make decisions when the person lacks capacity, within the scope of the LPA document. They must act in the person’s best interests and cannot require treatment that is clinically inappropriate.
Can families insist on CPR when it is clinically futile?
Families should be listened to and involved, but they do not have a right to demand clinically inappropriate treatment. The clinician has a duty to decide whether CPR is clinically indicated, while still involving and informing relatives sensitively.
Do you always have to consult the patient or family about DNACPR?
There is a strong presumption to consult the patient where they have capacity, and to consult those close to them when capacity is lacking, unless consultation would cause serious harm or is impracticable. Any decision not to consult should be clearly documented.
Are blanket DNACPRs ever acceptable?
No. DNACPR decisions must always be individualised and non-discriminatory. Blanket policies based on setting (for example care homes) or diagnosis are unlawful and unsafe.
• Involve patients in decisions about their care, including at the end of life, and be honest about risks, benefits and uncertainty (GMC end-of-life guidance).
• Respect legally binding ADRTs and consider the role of LPAs when patients lack capacity.
• Follow the MCA when capacity is in doubt, and make decisions in the patient’s best interests where capacity is lacking.
• Communicate sensitively and clearly with families and those close to the patient, recognising their needs while keeping the patient at the centre.
• Avoid discriminatory or blanket approaches to DNACPR and other end-of-life decisions.
• Keep clear, accurate, and contemporaneous records of end-of-life discussions, decisions, and review plans.
A 79-year-old man with advanced heart failure asks whether he can “sign a DNR”. He is fully oriented and able to explain his condition and priorities. He wants comfort and time with family, and is worried about a poor outcome from CPR.
Best action: Explore his values and understanding, explain what CPR involves and its likely outcomes in his situation, clarify that DNACPR covers CPR only and that other appropriate treatments will continue, check for any ADRT or LPA, agree a DNACPR and broader emergency care plan if appropriate, and document the discussion and review.
Why: This respects autonomy, provides realistic information, uses DNACPR correctly, and leaves a clear, individualised record.
✓ DNACPR is a decision about CPR only; it is not “do not treat”.
✓ ADRTs and Health and Welfare LPAs must be checked, understood, and respected where valid and applicable.
✓ End-of-life decisions should be individualised, not blanket or discriminatory.
✓ When capacity is lacking, follow MCA best interests with consultation and least restriction.
✓ Patients and those close to them should usually be involved in DNACPR decisions unless this would cause harm or is impracticable.
✓ Documentation of discussions, instruments, decisions, and review points is essential for safe practice.
✓ In SJT questions, answers that show early conversation, lawful checks, correct DNACPR scope, and clear records score best.
* → Capacity Assessment (Mental Capacity Act)
* → Consent in Adults
* → Working with Relatives and Carers
* → Advance Care Planning and ReSPECT
* → Resource Allocation and Fairness
* → Safeguarding & Vulnerable Adults
An 82-year-old woman with metastatic lung cancer is admitted with pneumonia. She is breathless but comfortable on oxygen and morphine and has capacity. She asks you “what would happen if my heart stopped” and whether it is possible to record that she does not want to be “brought back” if the chances are very low. Her daughter is present and looks worried but says she wants whatever her mother wants.
Options:
A. Reassure her that “we will always try everything” and defer the conversation about CPR.
B. Explain that CPR attempts to restart the heart and breathing, describe realistic outcomes in people with her condition, and explore what matters most to her.
C. Clarify that DNACPR applies only to attempted CPR and that other appropriate treatments and symptom control will continue.
D. Ask the daughter to decide instead of the patient because the topic is upsetting.
E. Check whether she has an ADRT or Health and Welfare LPA and, if not, offer to record her wishes in a DNACPR/ReSPECT or equivalent plan.
F. Complete a DNACPR without telling her, as discussing it would be distressing.
G. Tell her that if she signs a DNACPR, she will not receive antibiotics or oxygen in future.
H. Document the discussion, agreed DNACPR decision, who was present, and when it should be reviewed.
Correct three: B, C, E
• B: Provides honest information about CPR and explores values, enabling shared decision-making.
• C: Correctly explains that DNACPR is CPR-specific while other treatments continue, preventing undertreatment.
• E: Checks for ADRT/LPA and offers to record wishes in a formal plan, aligning care with her values.
Why others are weaker/wrong:
• A: Avoids necessary discussion and misses the chance for shared planning.
• D: Inappropriately transfers decision-making to the daughter when the patient has capacity.
• F: Excludes the patient from an important decision without justification, conflicting with case law and guidance.
• G: Misrepresents DNACPR as “do not treat”, risking undertreatment.
• H: Documentation is important but without the preceding honest, shared decision-making it is incomplete; on its own it does not address her current need for explanation and planning.
Example SJT — Rank 5 (best → worst)
An 84-year-old man with advanced COPD is admitted from a care home with sepsis. He is confused and lacks capacity. No family are present, and contact details are not immediately available. The care-home transfer letter states “DNACPR for all residents with severe COPD”. There is no documented individual DNACPR form, ADRT, or LPA in the records you can see.
Options:
A. Disregard the blanket statement; review his notes for any ADRT or LPA; consider his prognosis; make an individual MCA best-interests decision about CPR, complete a DNACPR/ReSPECT if appropriate, and document the rationale and review.
B. Apply DNACPR automatically to this admission because of the care-home statement.
C. Attempt to contact anyone who knows the patient (care home staff, GP, relatives); if none are available in time, make a best-interests decision about CPR based on clinical judgement and record it clearly.
D. Withhold all active treatments because “DNACPR means comfort care only”.
E. Avoid writing anything detailed in the notes about CPR decisions to reduce the risk of complaints later.
Ideal order: A (1) > C (2) > B (3) > D (4) > E (5)
• A: Best: rejects blanket DNACPR, checks for ADRT/LPA, applies MCA best interests, and documents an individualised DNACPR decision with review.
• C: Appropriate attempt to consult those who know him, then makes and documents a best-interests decision when consultation is limited by urgency.
• B: Recognises DNACPR but wrongly relies on a blanket statement; safer than withholding all care or avoiding documentation but still poor.
• D: Misuses DNACPR as “do not treat”, risking undertreatment and distress.
• E: Actively avoids documentation, undermining transparency and safe care.
