The Duty of Involving Patients in DNACPR decisions Dr Debra Swann Palliative Medicine Consultant Croydon University Hospital and St Christopher s Hospice.
Decisions relating to CPR 2007: old fashioned paternalism? 6. Clinical decisions not to attempt CPR When a clinical decision is made that CPR should not be attempted, because it will not be successful, and the patient has not expressed a wish to discuss CPR, it is not necessary or appropriate to initiate discussion with the patient to explore their wishes regarding CPR. Careful consideration should be given as to whether or not to inform the patient of the decision.
Decisions relating to CPR 2007 7. Decisions about CPR that are based on benefits and burdens If CPR may be successful., the benefits of prolonging life must be weighed against the potential burdens to the patient.. In these circumstances, discussion with the patient (or if the patient lacks capacity, those close to the patient) about whether CPR should be attempted is an essential part of the decision-making process.
Tracey vs. Cambridge University Hospitals NHSFT (June 2014) Hospital was wrong to place 'do not resuscitate' notice on terminally ill 63- year-old as court rules doctors have duty to consult with patients first. LOUISE ECCLES FOR THE DAILY MAIL PUBLISHED: 13:31, 17 June 2014 UPDATED: 09:19, 18 June 2014 "The fact that her death has led to greater clarity in the law gives us all some small comfort (David Tracey- husband 2014)
Background Mrs Tracey, from Ware, in Hertfordshire, was suffering from advanced lung cancer when she was taken to hospital after a serious car crash. Her husband and daughters were distressed when a "do not resuscitate" notice was put on her hospital records. It was cancelled after the family complained, though a second DNR order was later put in place - after talks with the family and two days before Mrs Tracey died at the age of 63. Since her death, Janet's husband, David, has fought for a full judicial review to seek clarity over DNR notices and consent.
The Outcome Doctors now have a legal duty to consult with and inform patients if they want to place a Do Not Resuscitate (DNR) order on medical notes, the Court of Appeal has ruled (2014).
Legal commentary "The judgement sends a clear message to all NHS Trusts, regulatory bodies and healthcare professionals that patients have a legal right to be informed and consulted in relation to decisions to withhold resuscitation. "The belief such information would cause distress is no longer a sufficient reason not to inform and consult with a patient. There must now be convincing reasons to displace this right. Lawyers Leigh Day, on behalf of the Tracey family. The ruling does not give patients the right to have CPR, but it does mean they should be consulted.
DNR A view by Daniel K. Sokol, Barrister and Medical Ethicist The decision.that the placing of a DNR order on Janet Tracey's medical notes without her knowledge was unlawful is a warning shot for all [health care settings] and hospitals in England. Doctors will need to justify DNR decisions and should make sure they keep a contemporaneous note about the discussions they have with the patients and families involved. The Court held that if a patient has capacity there should be a presumption that they should be involved in the DNR decision.
Daniel K. Sokol cont There must be 'convincing' reasons not to involve the patient - a clinician's belief that cardio-pulmonary resuscitation will fail is not enough. Neither is the fact that the patient may find the topic distressing. However, if the clinician believes that involving the patient in the process will cause the patient physical or psychological harm this could count as a convincing reason. This is the most problematic part of the judgment. The boundary between distress and psychological harm is unclear. Clinicians may attempt to justify their decision not to involve patients by claiming that disclosure would probably lead to psychological harm. (maleficence vs beneficence)
Tracey vs. Cambridge University Hospitals NHSFT (June 2014) 55. Lord Pannick [in his submission to the judicial review] submitted that it was inappropriate to involve the patient if the clinician forms the view that CPR would be futile even if he considers that involvement is unlikely to cause the patient harm. Courts rejected this submission for two reasons: 1. A decision to deprive the patient of potentially life-saving treatment is of a different order of significance for the patient from a decision to deprive him or her of other kinds of treatment. It calls for particularly convincing justification. Prima facie, the patient is entitled to know that such an important clinical decision has been taken. N.B The fact that the clinician considers that CPR will not work means that the patient cannot require him to provide it. It does not, however, mean that the patient is not entitled to know that the clinical decision has been taken.
Tracey vs. Cambridge University Hospitals NHSFT (June 2014) 2. If the patient is not told that the clinician has made a DNACPR decision, he will be deprived of the opportunity of seeking a second opinion. 65. In any event, I would accept the submission of Lord Pannick that there is no obligation to offer to arrange a second opinion in a case, such as that of Mrs Tracey, where the patient is being advised and treated by a multi-disciplinary team all of whom take the view that a DNACPR notice is appropriate.
Are you obliged to discuss in cases of Yes futility? Does NOT mean one is obliged to provide CPR if patient wishes But patient is entitled to know about the decision because - it has far-reaching implications for them - patient is entitled to a second opinion
Implications of this judgement Better communication with patients/ relatives Better documentation of DNACPR decisions Wider adaptation of ceiling of treatment forms that encourage more constructive discussions Discussion vs. consultation vs. informing Time to undertake these discussion even informing cam take considerable time Prediction of an increase in the number of futile CPR attempts with acutely ill patients OOH.- decisions being deferred.
Resource implications The possibility of life support on ITU is frequently not mentioned to acutely ill patients. Given existing and diminishing resources are these changes deliverable? N.B ITU beds Time from clinicians to hold and informed discussion with competent patients/ assessment of capacity prior to having the discussions
Process Patient deemed to have capacity and wishes to have the discussion Discussion around risks and benefits and potential outcomes Patient states they don't want CPR Clinician feels CPR would not be successful Clinician documents state of capacity for patient. Clinician documents on form and shares with relevant HCPs Form remains with the patient and a copy is held on the record N.B Patient/ nominated NOK is not required to sign it.
Winspear v City Hospitals Sunderland NHS Foundation Trust [November 2015] The BMA, Resuscitation Council (UK) and RCN have issued a response to the judgment in the High Court in the case of EWHC 3250 (QB). Carl Winspear- 28 Cerebral palsy, epilepsy, spinal deformities and other associated health conditions. Died 3.1.11 ref: Leigh Day website accessed 20.1.16
The BMA, RCUK and RCN statement following the judgment: Winspear v City Hospitals Sunderland NHS Foundation Trust [2015] EWHC 3250 (QB). The wording of the guidance in Decisions relating to cardiopulmonary resuscitation is under review. We will make any necessary changes to ensure that it is compliant with this most recent decision. For the present, we wish to emphasise the following points for attention when health professionals consider making an anticipatory decision about CPR for a person who does not have capacity to participate in the decisionmaking process:
1. The BMA, RCUK and RCN joint statement : In order to make a fully informed decision, where it is both practicable and appropriate, they must discuss the patient s situation and the decision with those close to the patient (subject to any confidentiality restrictions expressed if, and when, the patient had capacity).
2. The BMA, RCUK and RCN joint statement Where both practicable and appropriate, they should not delay contacting those close to the patient in order to do this. Of note, in the recent judgment it was stated by the judge that a telephone call at 3.00 am may be less than convenient or desirable than a meeting in working hours, but that is not the same as whether it is practicable.
3. The BMA, RCUK and RCN joint statement When it is not possible to contact those close to the patient immediately and an anticipatory decision about CPR is needed in order to deliver high-quality care, that decision should be made in accordance with the relevant legislation. These recommendations apply when a decision is being considered because attempting CPR would not succeed in preventing a patient s death, or when a decision about CPR is being considered on a balance of risk and benefit in a patient s individual situation at that time.
A thank you letter to David Bowie And I doubt that anyone will have given you Cardiopulmonary Resuscitation (CPR) in the last hours/days of your life, or even considered it. Regrettably, some patients who have not actively opted out of this treatment still receive it, by default.... It is very likely that you asked your medical team to issue you with a DNACPR order. I can only imagine what it must have been like to discuss this, but you were once again a hero, or a Held, even at this most challenging time of your life. 15 Jan, 16 by BMJSPCblog Dr Mark Taubert, Palliative Care Consultant at Velindre NHS Trust, Cardiff, UK @DrMarkTaubert David Bowie- 8 January 1947 10 January 2016)
Any Questions?