A special thank you to Julie Donovan who went out of her way to explain things in plain English and kept me informed.
DNRs and DNACPRs – What you Should Know
Wed 7th Dec 2011 Clinical negligence
The Guardian published an article on Tuesday 6th December 2011 about concerns that have been raised by the Care Quality Commission about at least eight NHS Hospital Trusts and the way that DNR Orders are added to patients' records.
For the lucky uninitiated a
DNR Order is a Do Not Resuscitate Order and a DNAPRC Order is a Do Not Attempt
Cardiopulmonary Resuscitation Order.
The article did not mention any of our local hospitals, but that does not mean to say that local families do not have concerns about how a DNR Order comes to be placed in their relatives' records.
What does a DNR Order mean?
A DNR (or DNACPR) Order, is a direction that if a patient goes into cardiac arrest, artificial attempts to restart their heart or breathing, should not be taken. If they recover on their own, without this intervention, then all attempts will of course be taken to keep them alive and as healthy as possible. However if their heart does not start to beat unaided, then no intervention will take place, and if the status quo remains, the patient will be allowed to pass away.
What Guidance is in Place?
The article in the Guardian quite rightly cites that there is no national government guidance on the imposition of a DNR Order and that the "Final word lies with doctors". However, Guidance is available and should be adhered to from the BMA (British Medical Association), the RCN (Royal College of Nursing) and the Resuscitation Council. All of this guidance states that a patient's views should be "absolutely central" to matters taken into account and that families' views, where their loved one is not able to give an opinion, perhaps if they are unconscious, should also be given due consideration. Furthermore, each NHS Trust has a local guideline that they are expected to adhere to.
University Southampton Hospital NHS Foundation Trust, which is responsible for SouthamptonGeneralHospital, the RoyalSouthHantsHospital, Countess Mountbatten House, The Princess Anne Hospital and New Forest Birth Centre, relies upon guidance from NHS South Central. This provides that if the clinical team consider that there is no realistic chance that CPR will be successful, it should not be attempted.
However, where this is not the case, CPR should take place unless the potential risks and burdens of CPR are considered to be greater than the likely benefit of CPR, and even in these circumstances, that the wishes of the patient should guide the decision making. . If the person does not have capacity to make a decision in their own right at that point in time, then the views of those closest to the individual should be considered crucial, unless an Advance Directive from the patient is in place (pre-disclosed wishes), in which case they should be paramount.
Where there is disagreement as to the value of resuscitation attempts with the patient, the guidance provides:
"Individuals may insist on CPR being undertaken even if the clinical evidence suggests that it will not provide any overall benefit. Sensitive discussion with the person should aim to secure their understanding and acceptance of the DNACPR decision. Although individuals do not have a right to demand that doctors carry out treatment against their clinical judgement, the person's wishes to receive treatment should be respected wherever possible.
Where the decision is seriously challenged and agreement cannot be reached, legal advice may be indicated."
Portsmouth Hospitals NHS Trust, which is responsible for the QueenAlexandraHospital, St Mary's Hospital, Blake Maternity Centre and Grange Maternity Centre, relies upon guidance produced by the Trust. This guidance provides that where the clinical team feel that the heart and lungs cannot be started then resuscitation should not be attempted.
However, in other circumstances there is a presumption in favour of CPR where no prior consideration has been given to the issue. Where the benefits and burdens of CPR have to be taken into consideration, the patient's wishes should be taken into account where possible. If it is not possible to discuss this with the patient, full discussion should be held with those closest to the patient, but the guidance states that ultimately the decision rests with the most senior clinician available and should be based upon the best interests of the patient. The doctor making the decision must be Grade ST 3 or above and this should be approved by a Consultant. The decision to place a DNR decision in a patient's records in those circumstances should have a clear rationale and be fully explained.
Under the Portsmouth policy:
- Adults are those aged 16 and over;
- Information should not be forced onto patients [and] if they express they do not wish to discuss CPR this should be respected;
- The patient should be informed in a sensitive manner of the facts, including possible risks and adverse effects of CPR to enable them to make an informed decision as they may have unrealistic expectations about the likely success and benefits of CPR.
- Where the patient does not have capacity all attempts should be made to discuss these points with family or loved ones.
As a family member a DNR Order is always a very sombre issue to have to discuss. As a patient who may be the subject of such an order, it may be a very frightening experience, or it may be something that you have already put a lot of thought into. Many people nowadays have Donor cards, Wills and even Living Wills, (or Advance Directions) where they have given quite a lot of consideration to what they wish to happen to themselves if the worst were to happen. As a family member though where none of these issues have been previously considered, it will always be extremely difficult and upsetting.
The Guardian Article refers to a gentleman whose wife sadly passed away at Addenbrooke's hospital without medical intervention, in circumstances where he believed no or little consideration was given to either his or his wife's wishes, and he calls upon the government to produce a national policy on DNRs.
Whilst I have little doubt that doctors wish to do their very best by their patients and to act in their best interests, even the two local Guidelines for DNR policies referred to above have their differences. Sadly I have heard of many cases, both locally and nationally, where from the family perspective at least, these or any similar guidelines were simply not followed. I have come across a case where a patient who had not even be told that she had incurable cancer because her results hadn't yet been reported to her, was admitted with an unrelated infection and placed on an almost immediate DNR. She died very shortly thereafter in the hospital as a consequence of the untreated infection. Her husband, also unaware of the underlying diagnosis, was unsurprisingly distraught at the lack of treatment she had received and the very sudden loss of his wife.
I have also talked with a gentleman whose wife was seriously unwell, and apparently had the potential CPR attempts graphically described to her, including breaking her ribs and hand massaging her heart, should she not agree to a DNR Order This surely does not meet with anyone's interpretation of the phrase "sensitive discussion".
I have looked into numerous cases where the relatives say that they did not know that a DNR Order had been placed on the records until they had either requested further information themselves, or had instructed solicitors. Whilst I firmly believe that autonomy and confidentiality must at all times remain with the patient if they decide not to disclose their wishes to their family members, in all of these cases, this was not the issue. In a number of cases the medical records state "Family aware [Patient] seriously ill," or "DNR discussed". But again in all of these situations, the family had no true appreciation of the gravity of the situation when viewed alongside the medical records.
When a spouse, relative or good friend of a patient hears "seriously ill", they do not often appreciate that this means that their loved one might die. They know they are ill, but they are in hospital and believe that that individual will get better with the right medical intervention. Similarly discussions about "DNR" Orders with the closest family members are not fully understood by a shocked and upset husband, wife, son or daughter. Entries within the medical records of "DNR discussed with family" do not represent a full and frank discussion of the implications of such an order. Nor, where the patient does not have capacity, do they provide evidence of the fact that the wishes of the patient's closest friends and family have been taken into account.
In the majority (but not all) of situations that I have come across in my career as a clinical negligence
Lawyer, the decisions that have been made by medical professionals have been legally made and the decision as to whether or not CPR intervention is or is not in the interests of a patient is made by an appropriately qualified medical professional. It is not always clear though that this decision has been taken with the patient's, or their family's views, properly taken into account. It must also be remembered that the decision to place a DNR Order in a patient's notes must not be made too hastily; it is after all the last decision that a patient, or the treating doctors' on their behalf, may make.
I should like to ask that all doctors, nurses, treating and caring professionals bear these comments in mind, and take the time to record the rationale for all DNR decisions clearly in their notes, and most of all, to communicate this to their patients and the family and friends that those patients may leave behind.
1. Clinical Policies: Do Not Attempt Cardiopulmonary Resuscitation Policy
2. Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Adult Policy
3. Resuscitation: final word lies with doctors (guardian.co.uk)
4. NHS hospitals warned over 'do not resuscitate' orders (guardian.co.uk)
For further information, please contact Kym Provan, a Senior Solicitor in our Clinical Negligence team, on 02380857317 or at firstname.lastname@example.org
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