How to Coordinate Your Advance Directive with ReSPECT and DNACPR in Scotland

If you have an advance directive in Scotland, it does not replace your ReSPECT form or any DNACPR order — and neither of those documents replaces it. All three exist for different reasons, cover different decisions, and are created through different processes. But they must align, because a clinician making an emergency treatment decision at 3am will look at whichever document is in front of them, and contradictions between the three create exactly the kind of ambiguity that leads to treatment you did not want.

The coordination challenge is practical, not legal. Your advance directive is a patient-authored document under Scots common law. The ReSPECT form is a clinician-completed summary of recommended care in an emergency. A DNACPR order is a specific clinical decision about cardiopulmonary resuscitation. They are produced at different times, by different people, through different conversations — and unless someone ensures they say the same thing, they may not.

The Three Documents at a Glance

Why Coordination Matters

Here is the scenario that creates problems: you sign an advance directive refusing CPR and mechanical ventilation under specified circumstances. Your GP uploads it to the KIS. Months later, you are admitted to hospital. The hospital consultant conducts a ReSPECT conversation with your family and completes a ReSPECT form — but the consultant has not seen your advance directive, either because the KIS upload was incomplete or because the hospital team did not check. The ReSPECT form records a preference for "modified active treatment" without mentioning your specific ventilation refusal. A DNACPR order is not completed because no one raised it.

At 3am, you go into cardiac arrest. The on-call team looks at the ReSPECT form, sees "modified active treatment," and begins CPR. Your advance directive refusing CPR exists in the KIS — but the team checked the ReSPECT form first, and it said something different.

This is not a hypothetical. It is the predictable result of three documents created independently, at different times, by different people, without anyone checking alignment.

Who This Is For

• Anyone in Scotland who has signed or is about to sign an advance directive and wants to ensure it actually influences their ReSPECT form and any DNACPR discussions
• Families whose parent is in hospital and wants to make sure the clinical team's documentation matches the advance directive already on file
• Adults who have a KIS entry and want to verify that their GP has noted their advance directive preferences in a way that clinicians can actually find and use
• Caregivers coordinating between GP practices, hospital teams, and care homes — where documents may exist in multiple systems without cross-referencing

Who This Is NOT For

• Anyone who does not yet have an advance directive — start with drafting and the KIS upload before worrying about coordination with clinical documents
• People in England or Wales — the clinical frameworks (Summary Care Record, ADRT statute) differ from Scotland's KIS and common-law approach
• Families who want a clinician to complete all three documents for them — the advance directive must be patient-authored, while the ReSPECT and DNACPR are clinician-led with patient input

Step-by-Step Coordination

Step 1: Draft the Advance Directive with Clinical Specificity

The advance directive is the anchor document. It is the only one you write yourself, and the one that records your specific treatment refusals. The ReSPECT form and DNACPR order should reflect what it says, not the other way around.

Each treatment refusal in the advance directive should be specific enough that a clinician completing a ReSPECT form or considering a DNACPR order can read it and know what to record. "No extraordinary measures" is too vague to inform either document. "I refuse cardiopulmonary resuscitation in all circumstances, acknowledging that this refusal may result in my death" maps directly to a DNACPR order. "I refuse mechanical ventilation if I have been diagnosed with a progressive neurological condition and have lost the ability to communicate" maps directly to a specific ReSPECT recommendation.

Step 2: Upload to the KIS and Tell the GP What to Record

When you send the GP practice request letter for the KIS upload, include a summary of the key clinical decisions your directive covers — particularly CPR, ventilation, and any condition-specific refusals. The GP enters information into specific KIS fields, and a summary note that says "see attached advance directive" is less useful than one that says "patient refuses CPR in all circumstances; refuses mechanical ventilation in the event of progressive neurological decline; refuses artificial nutrition via PEG tube in end-stage dementia."

The KIS entry should reference the advance directive and summarise its core decisions, so that any clinician reading the KIS gets the key information immediately without having to locate and read the full document.

Step 3: Raise the ReSPECT Conversation with Your GP

The ReSPECT form is a clinician-led document, but the conversation that informs it should include you. Ask your GP (or hospital consultant, if you are an inpatient) to complete or update the ReSPECT form in light of your advance directive. Bring a copy of the directive to the appointment. Walk through the key decisions together.

The goal is for the ReSPECT form to reflect, not contradict, your directive. If your directive refuses CPR, the ReSPECT form's recommendation on the treatment escalation scale should be consistent with that refusal. If your directive refuses ventilation under specified conditions, the ReSPECT form should note those conditions.

ReSPECT is not a legally binding document — it is a clinical recommendation. But it is often the first document a clinician reads in an emergency because it is designed to be quick and clear. If it aligns with your advance directive, the two documents reinforce each other. If it contradicts your directive, the clinician has to make a judgement call under time pressure.

Step 4: Discuss DNACPR Separately

A DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) order is a specific clinical decision, not a patient instruction. Clinicians are not obligated to attempt CPR if it would be futile, regardless of what the patient wants. But where CPR has a reasonable chance of success and the patient has a valid advance refusal of CPR, the DNACPR order should reflect that refusal.

If your advance directive includes a CPR refusal, ask your GP or hospital consultant to record a DNACPR order that references the directive. The DNACPR order is what the resuscitation team sees first — it is designed for split-second decisions. An advance directive refusal of CPR is stronger in legal terms, but the DNACPR order is faster in clinical terms. Having both, aligned, is the safest position.

Step 5: Audit Annually (or After Any Hospital Admission)

Documents drift. A hospital admission may trigger a new ReSPECT conversation that produces a form inconsistent with your directive. A care home may complete its own care plan without referencing your KIS entry. A new GP at your practice may not know the directive exists.

Once a year — or after any hospital admission, care home placement, or change of GP — check that:

• The KIS entry still reflects your directive's key decisions
• Any ReSPECT form on file is consistent with your directive
• Any DNACPR order references or aligns with your CPR refusal
• Your GP practice has a copy of the current version of your directive

This takes 15 minutes and a phone call to the surgery. It prevents the drift that makes three well-intentioned documents work against each other.

The Scots Law Directive System and Clinical Coordination

The Scots Law Directive System includes specific tools for this coordination process. The advance directive drafting worksheets produce treatment-by-treatment refusals with the clinical precision that maps directly to ReSPECT recommendations and DNACPR decisions. The GP practice request letter includes the clinical codes and field references that make the KIS upload actionable. And the ReSPECT alignment guidance explains how to raise the conversation with your clinician and what to check for consistency.

The toolkit also covers the wider context — Welfare and Continuing Powers of Attorney, the OPG registration process, organ donation under Scotland's opt-out system, and the estate administration roadmap — because advance care planning is not just about the directive. But for the specific question of how to make three overlapping clinical documents work together instead of against each other, the coordination guidance is the critical piece.

Tradeoffs

Patient control vs clinical discretion: Your advance directive is the only document you control directly. The ReSPECT form and DNACPR order are clinician-led. You can influence them by raising the conversation and providing your directive, but you cannot dictate what a clinician records. The best outcome is alignment through conversation, not instruction.

Specificity vs flexibility: The more specific your advance directive, the more clearly it informs the ReSPECT form and DNACPR order. But extreme specificity can miss situations you did not anticipate. The ReSPECT form's treatment escalation scale provides the flexibility to cover scenarios your directive does not address. The combination of a specific directive and a flexible ReSPECT form is stronger than either alone.

One-time setup vs ongoing maintenance: Drafting and uploading the advance directive is a one-time task. Keeping it aligned with clinical documents that get updated during hospital admissions, care home placements, and GP changes is ongoing. The annual audit step is simple but essential.

Frequently Asked Questions

Does a ReSPECT form override my advance directive?

No. A ReSPECT form is a clinical recommendation, not a legally binding document. Your advance directive under Scots common law carries stronger legal weight because it records your own decisions made with capacity. However, in practice, the ReSPECT form is often the first document a clinician reaches for in an emergency because it is designed to be read quickly. If the two documents contradict each other, the clinician faces an immediate judgement call. The solution is alignment, not hierarchy — make sure they say the same thing.

Can I refuse CPR in my advance directive even if the doctor thinks CPR could work?

Yes. Under Scots common law, you have the right to refuse any treatment, including CPR, even if the refusal will result in your death — provided you made the refusal with capacity, voluntarily, with understanding of the consequences, and the refusal applies to the current clinical situation. A clinician is not obligated to attempt CPR against a valid advance refusal, even if CPR has a reasonable chance of success. This is distinct from situations where the clinician decides CPR would be futile — that is a clinical decision, not a patient refusal.

Who completes the ReSPECT form?

The ReSPECT form is completed by a clinician — typically your GP, a hospital consultant, or a senior nurse — after a conversation with you (or your welfare attorney or family if you lack capacity). You cannot complete a ReSPECT form yourself. But you can initiate the conversation, bring your advance directive to the discussion, and ask the clinician to ensure the form reflects your documented preferences.

What if the hospital creates a new ReSPECT form that contradicts my directive?

This can happen, particularly during an admission where the clinical team has not reviewed your KIS entry or is unaware of your advance directive. If you discover that a new ReSPECT form contradicts your directive, raise it with the clinical team immediately. Ask them to review the directive, amend the ReSPECT form, and note the directive in the hospital record. If you have a welfare attorney, they can advocate on your behalf. The annual (or post-admission) audit step is specifically designed to catch these inconsistencies.

Does a DNACPR order expire?

DNACPR orders should be reviewed when clinical circumstances change — a hospital admission, a transfer to a different care setting, or a significant change in the patient's condition. A DNACPR order recorded during a hospital admission should be carried over to the community record if it remains clinically appropriate. In practice, some DNACPR orders are not carried over, which is another reason the advance directive and KIS entry matter — they persist across care settings even when individual clinical documents do not.

See more Scotland guides →