Hospital Dr News

Doctors must consult over DNR decisions

Doctors have a legal duty to consult patients and their relatives before placing Do Not Resuscitate (DNR) orders in their medical notes, the Court of Appeal has ruled.

The landmark judgement says doctors must have “convincing reasons” not to involve patients in such decisions.

Current guidance already recommends that patients and families should be consulted but this ruling confirms for the first time that doctors have a legal obligation to do so.

The hearing was instigated by relatives of 63-year-old Janet Tracey who died three years ago in Addenbrooke’s Hospital, Cambridge, where she was taken for injuries sustained in a car accident. At the time Mrs Tracey also had a terminal lung cancer diagnosis.

The judge, Lord Dyson Master of the Rolls, found that doctors breached Mrs Tracey’s right to respect for her private life under Article 8 of the European Convention of Human Rights when they put a DNR notice on her file without telling her or her family.

He said Mrs Tracey had had capacity at the time and had expressed a clear wish to be involved in discussions about her treatment.

However the judgement recognises that this is a highly complex area of medical practice and ethics.

Lord Dyson said: “It would probably be impossible to devise a scheme which is completely free from difficulty. The problems generated by decisions whether or not to impose DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) notices are inherently fraught. The question whether to consult and notify the patient is inevitably one of the utmost sensitivity and difficulty. Whether it is appropriate to consult will depend on a difficult judgment to be made by the clinicians.”

In a statement, the Resuscitation Council (RC) said the judgement emphasised that doctors should be wary of being too ready to exclude patients from “the process” on the grounds that their involvement would be likely to distress them.

“Many patients may find it distressing to discuss the question whether CPR should be withheld from them in the event of a cardiorespiratory arrest. If the clinician forms the view that a patient will not suffer harm if they are consulted, the fact that they may find the topic distressing is unlikely to make it inappropriate to involve them,” it said.

Following the judgement the Resuscitation Council is advising all clinicians who may be required to undertake sensitive discussions and explanations about DNR decisions to ensure they have the necessary communication skills.  It also stresses that doctors should clearly document their reasons should they decide not to discuss a DNR decision with a patient or explain it to them.

Dr Pallavi Bradshaw, medicolegal adviser at the Medical Protection Society, said: “The legal and professional obligations on doctors remain unchanged except in emphasis. It has always been good practice to discuss issues of resuscitation with patients. Ideally, discussions should happen proactively at the time of admission and healthcare professionals should not fear having such conversations.

“In emergency or unforeseen situations doctors can still rely on the provisions of the Mental Capacity Act in considering the best interests of incapacitated patients, and where possible this should include discussions with the family.

“The ruling confirms the principle of patient autonomy and the need for open and frank discussions about end of life issues. It does, however, make it clear that there is a presumption of patient involvement and that there would need to be convincing reasons not to do so, even where the clinical view is that CPR would be futile.”

Dr Michael Devlin, Head of Professional Standards and Liaison at the MDU, said: “In confirming that patients should be involved in do not attempt resuscitation decisions about them, the Court of Appeal judgement states what was already part of ethical and professional guidance.

“Patients should be consulted when do not resuscitate decisions are being taken, even if it is distressing for them.  Rarely, doctors may decide that involving a patient in decisions of this nature would be harmful to their physical or mental health, but must be prepared to justify, and have convincing reasons for, their decision not to involve the patient.”

Dr Keith McNeil, Chief Executive of Cambridge University Hospitals NHS Foundation Trust, said the ruling hinged on a specific point of law and there was no criticism of their clinical care. “It is a fact of life that every day people die in hospitals. From my own experience as a specialist hospital doctor, the most important thing is that these patients are treated with the utmost respect and dignity,” he said.

Dr Tony Calland, Chair of the BMA’s Medical Ethics Committee, said they would now be updating their guidance in line with any developments in policy and legislation.

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