DNARpaed.1(June 2009)

DO  NOT  ATTEMPT  CARDIOPULMONARY  RESUSCITATION

Children less than 16 years of age

Name

Address

Date of birth

NHS or hospital number

Date of DNAR order: 

            /       /

DO NOT PHOTOCOPY 

In the event of cardiac or respiratory arrest no attempts at cardiopulmonary resuscitation (CPR) will be made.  All other appropriate treatment and care will be provided.

YES / NO

1 

YES / NO

YES / NO

YES / NO

2

Review date (if appropriate)

7

3

4

5

6

	1a.	Does the child have capacity to make and communicate decisions about CPR?
	If “YES” go to 1b.  If “NO” go to 1c.
1b.	Has the child been involved in the decision making process of this order?
	Now go to 1c.
1c.	Have the child’s parents (or those holding legal parental responsibility) 
	been consulted and agreed to the application of this order?  If “YES” go to box 2.
1d.	Has a Court made an order in respect of this decision?  If “YES” go to 1e.
If the answers to both 1c and 1d are “NO”, legal advice must be taken before proceeding.
All other decisions must be made in the child’s best interests and comply with current law.
1e.	Date, time, location and name of Judge/Court making order:

	Summary of the main clinical problems and reasons why CPR would be inappropriate,
	unsuccessful or not in the child’s best interests:

	Name of person(s) holding parental responsibility and summary of communication with them:

	Names of members of multidisciplinary team contributing to this decision:

	Healthcare professional making this DNAR order:

Name	Position

Signature	Date	Time

	Review and endorsement by most senior health professional:

Signature	Name	Date  

Signature	Name	Date

	Summary of communication with child.  If this decision has not been discussed with the child 	state the reason why: