The current debate

Do Not Resuscitate orders (DNRs) have recently become the subject of much debate. This follows media exposure of a case in which an NHS Trust in East Kent issued a patient with Down’s syndrome (identified only as AWA) with a DNR order, without his or his family’s consent. His family are now suing the Trust.

AWA had dementia and was fed by a tube through his stomach. In his DNR order, disability was cited as the sole reason for the imposition of the order. Members of AWA’s family had been at the hospital on a daily basis and there were numerous opportunities for them to have been consulted on the decision to withhold treatment.

The case highlights either a serious miscommunication error or, perhaps, a deliberate decision taken by doctors based on their assessment of AWA’s quality of life.

In this article we look at the consequences of this decision and the wider implications. The article will also question whether there is the need for a nationwide policy for DNR orders rather than leaving it to individual NHS Trusts.

Two key aspects: communication and consent

DNRs or DNACPR (“do not attempt cardiopulmonary resuscitation”) are written instructions to withhold CPR in the event of a cardiac or respiratory arrest.

CPR is a highly invasive intervention. It involves chest compressions, defibrillation, artificial ventilation and can involve the injection of drugs to restart the heart. For patients who have experienced a stroke, a severe injury/infection, cancer, or liver failure, resuscitation will very often fail, and there is no way of knowing, in advance, what condition a patient will be left in – even if they are successfully resuscitated. In the case of a serious stroke for example, there is a risk that a resuscitated patient will be left in a permanent state of either partial or full paralysis. There are many who would not wish to live in those circumstances, particularly if they are elderly, and/or have a terminal condition which would otherwise end their life in the near future. They would instead prefer, following a significant cardiac arrest or respiratory failure, that they simply “…do not wake up”. Some make that choice in advance and communicate it to their treating doctors so that all are aware of the position.

Underpinning any decision on CPR, it remains the case that doctors cannot be expected to (and are not legally obliged to) provide a treatment or intervention which they do not believe is going to work, or which is not in the patient’s best interests.

This was illustrated very recently in a case where the family of a severely brain-damaged Muslim patient wanted every possible intervention to be undertaken with a view to prolonging his life. His doctors had decided that, if his condition worsened, it would not be in his best interests to attempt resuscitation. The family said that not to do so was against their Muslim faith. The court found in favour of the doctors, who were permitted to withhold life sustaining treatment on the basis that this would not prolong the patient’s life “in any meaningful way”.

Guidelines

The British Medical Association/Royal College of Nursing and the General Medical Council have issued guidelines on the issue. They are as follows:

  • BMA, Resuscitation Council (UK) and RCN – “Decisions relating to Cardiopulmonary Resuscitation”
  • GMC – “Treatment and care towards the end of life: good practice in decision making”

The guidelines identify three situations in which withholding CPR may be legally and ethically justifiable.

  1. The patient has made an advance decision (living will);
  2. Clinical judgement concludes that CPR will not be successful in restoring the patient’s heart, breathing and circulation – for example, if a patient is dying from another irreversible condition;
  3. When, following careful discussion with the patient and/or those close to him, there is an agreement that the benefits of CPR are outweighed by the burdens and risks.

The guidelines emphasise the importance of communication, which appears to have been so lacking in this case. If a patient does not wish to discuss the issue, it should be raised with the family in appropriate circumstances, though with the proper constraints of patient confidentiality and the patient’s express wishes in mind. It is important to remember that only the patient, if they have capacity, can request or mandate a DNR order, or make an advance decision refusing future treatment.

In circumstances where the clinical view is that CPR or other intervention would be futile or would not be in the patient’s best interests, doctors may, unilaterally, decide to withhold treatment. However, that should, if at all possible, be discussed with the patient and/or their relatives and there can be very few situations in which that clinical decision should be taken in private, and kept from the patient and/or their family.

The vast majority of DNR orders are agreed with patients, or are implemented at their request. Although most, if not all, trusts will have a written policy or guidance in place, the implementation of a nationwide policy would create a recognised framework which would, arguably, encourage the openness and transparency that this issue requires and deserves.

It would also provide a measure of protection to the clinical staff provided that its requirements had been followed. This is also important as it must be remembered that the placing of a DNR order on a patient’s file without proper consideration, care or clinical judgement, is unlawful. Any such act is punishable both by the GMC (in the case of a doctor) as regulator, and possibly by the courts, in criminal law. It follows also that civil liability may attach.

Law/ethics/medicine

This issue is one which requires, in each case, very careful consideration of the individual patient’s clinical condition, the wishes of the patient or their relatives, and the law and principles of both legal and medical ethics. Decisions often have to be made in fast moving and highly charged situations where there may not be the luxury of time. It is for exactly that reason that these issues should be considered in advance, and discussed openly with the people involved, wherever possible.