NORTH STAFFORDSHIRE HOSPITALS AND PRIMARY CARE TRUSTS
DO NOT ATTEMPT RESUCITATION (DNAR) PROFORMA
THIS FORM DOES NOT CONSTITUTE PART OF THE
MEDICAL RECORD
Name .............................................................
This proforma is to be completed by the Consultant/Staff
Grade/Registrar/General Practitioner. The proforma
should be kept inside the patient’s medical notes within
the hospital setting and in nursing/patient held records
within Primary Care
Address ..........................................................
........................................................................
DOB ...............................................................
Unit No ..........................................................
ATTACH PATIENT LABEL (if available)
THE DNAR ORDER AND REVIEWS MUST BE WRITTEN PROMINENTLY IN THE MEDICAL NOTES BY THE DOCTOR MAKING THE
DECISION.
Please read notes on reverse of this form.
Date
Doctors Name
(PRINT)
Doctors
Signature
Grade
Ward/
Setting
Documented in
notes (tick)
Nurses Name
(PRINT)
Nurses
Signature
Review
Date
Has the decision not to resuscitate been discussed with the patient? YES/NO
N.B. THIS PROFORMA SHOULD BE DESTROYED WHEN THE PATIENT IS IDENTIFIED FOR RESUSCITATION.
Any change in a patient’s condition that results in change of resuscitation status must be recorded in the patient’s notes and documented that
the DNAR proforma was destroyed.
Guidelines for physician regarding Resuscitation Status
 There must be a multidisciplinary discussion about the patients’ condition before any decision not to attempt resuscitation is made.
 The wishes of the patient and relatives should be considered where appropriate; in the decision making process and it is the consultants’
responsibility to ensure that this is the case.
 The DNAR order and reviews must be written prominently in the medical records by the doctor making the decision ‘Not for
cardiopulmonary resuscitation’ or words to that effect MUST BE WRITTEN IN FULL with the date, time, clinical justification, and those
consulted with their views and the patients documented consent if applicable. The notes must then be signed and the name and job title
must be printed.
 The proforma should be completed to alert clinical staff involved in the care of that patient that a DNAR decision has been made.
 A DNAR order applies solely to Cardiopulmonary resuscitation and does not affect any other aspect of treatment.
 A DNAR order is acceptable only if it is deemed in the ‘best interest of the patient.’ Circumstances that warrant a DNAR order include.
o If the patients life expectancy is very short
o Resuscitation presents an unacceptable probability of brain damage or death even if successful.
o The resulting length and quality of life would not be acceptable to the patient.
o If the resuscitation is against a mentally competent patients sustained and documented wishes including Advanced Directives.
 Regular review of resuscitation status must be undertaken to allow for changes in the patient’s condition and wishes. The frequency of
the review should be determined by the health professional in charge and will be influenced by the clinical circumstances of the patient.
It is important to note that patient’s abilities to participate in decision making may vary over time.
 The senior nurse present who is responsible for informing the health care team records the DNAR order and reviews in the nursing notes.