Ambulance Directive X in selected box then select text and strike through (or delete) content in other boxes: Attempt full Attempt Cardiopulmonary Resuscitation with DO NOT attempt Cardiopulmonary modifications Cardiopulmonary Resuscitation Resuscitation DNACPR Select Select Select Attempt CPR as DNACPR Yes No INTUBATION per Resuscitation Council (UK) Patient-specific AIRWAY AND guidelines. supportive care is BREATHING - - - - - - - - - - documented on - - - - 7, 8 and 9 CIRCULATION - - - - - - -- - - - - - - - Yes No PICU Clinician 2nd Clinician lead clinician) (2nd Signature may be required if lead clinician has not signed (usually and countersigns at a later date) Clinician Name Clinician Name Professional Professional Role/ Grade Role/ GMC/ (NMC) No. GMC/ (NMC) No. Signature Signature Date Date www.cypacp.nhs.uk
Ambulance Directive X in selected box then select text and strike through (or delete) content in other boxes: Attempt full Cardiopulmonary Resuscitation Attempt Cardiopulmonary Resuscitation with modifications DO NOT attempt Cardiopulmonary Resuscitation DNACPR Select Select Select Attempt CPR as per Resuscitation Council (UK) guidelines. - - - - - - - - - - - - - - INTUBATION Yes No DNACPR Patient-specific supportive care is documented on 7, 8 and 9 - - - - - - -- - - - - - - - AIRWAY AND BREATHING CIRCULATION PICU Yes No Clinician (usually lead clinician) 2nd Clinician (2nd Signature may be required if lead clinician has not signed and countersigns at a later date) Clinician Name Clinician Name Professional Role/ Grade Professional Role/ GMC/ (NMC) No. GMC/ (NMC) No. Signature Signature Date Date www.cypacp.nhs.uk
CYPACP-Musgrove-Park-v1.1-no-macro.docx