The UHL DNACPR Process in Practice: An Audit of Documentation, Communication and Signatory Compliance

Abstract Background The aim of the UHL DNACPR policy is to provide a decision-making framework to facilitate the timely discussion of CPR and DNACPR orders regarding patients of the UL Hospitals Group and to ensure that decisions relating to CPR and DNACPR orders are made consistently, transparently and in line with best national and international practice. This audit aimed to assess the current use of the UHL DNACPR form in clinical practice against the official UHL DNACPR policy. Methods The healthcare records of all medically admitted patients were reviewed using a point prevalence approach across 14 wards and the Emergency Department in UHL on 11/4/25. Pre-specified data points were collected from each healthcare record including assessment of patient capacity, documentation of discussions related to decision making and the signatures of those involved in those discussions. No personal data was collected. Results 75/247 (23.1%) of the 324 patients medically admitted to UHL on 11/4/25 had a DNACPR form in their medical charts. 3 of these were from previous admissions. Of the 72 patients with current DNACPR forms 31% were female. 62/72 (86%) DNACPR forms were signed by an NCHD. 26/72 (36%) were signed by a consultant. 8/72 (11%) were signed by a nurse. 46/72 (63.8%) were signed only by an NCHD. 11 DNACPR forms that were signed only by an NCHD had no documented discussion with the patient or their family member. Conclusion NCHDs assume a significant level of professional risk as the sole-signatories of DNACPR forms, particularly when forms are signed without documentation of discussion with patients and/or family members. Training for NCHDs, nurses and consultants on the appropriate use of the UHL DNACPR form should ensure that patient-centred decision making is a) undertaken and b) appropriately documented by all relevant staff (NCHD, consultant and nursing), for all DNACPR discussions and decisions in UHL.