Capacity, best interests, DNACPR and ReSPECT

Why this matters on day one

These decisions are made on ward rounds daily and are frequently done badly. The law is specific, the process is documented, and getting it wrong causes real harm — either treatment someone did not want, or a decision made without them.

The sequence

1. 1The five principles. Presume capacity. Take all practicable steps to support the person to decide. An unwise decision is not incapacity. Act in their best interests. Choose the least restrictive option.
2. 2The two-stage test. First, is there an impairment of mind or brain? Second, does it mean they cannot understand, retain, weigh or communicate this decision? Capacity is decision-specific and time-specific — it is not a global label.
3. 3Best interests. If they lack capacity: consider their past and present wishes, beliefs and values, any written statement, and consult those close to them and any attorney or deputy. Family do not consent on an adult's behalf unless they hold a health and welfare LPA. An IMCA is required for serious decisions where nobody else is available.
4. 4DNACPR. A clinical decision about ONE intervention — that CPR would not work or would not be in their interests. It is not consent-based, but the patient (or those close to them, if they lack capacity) must be consulted and informed; failing to do so was unlawful in Tracey. It does NOT mean withholding other treatment.
5. 5ReSPECT. A broader recommendation summarising what matters to the person and what treatments are and are not recommended, including but not limited to CPR. It travels with the patient and should be revisited when the situation changes.

What goes wrong

• Treating capacity as global rather than decision-specific.
• Asking a family to "consent" for an adult who lacks capacity.
• Deciding DNACPR without any discussion with the patient or family.
• Assuming DNACPR means not for antibiotics, fluids or escalation.
• Not checking for an advance decision to refuse treatment or an LPA.