DNAR: A matter of life and death

Decisions not to attempt resuscitation have generated considerable controversy recently. As many as 40% of resuscitation attempts in hospitals may be inappropriate, a common complaint being insufficient involvement of carers or family in the decision.

At the heart of the controversy lies a tension in the legal obligations imposed on clinical staff. Healthcare professionals have a duty to patients to offer care to a reasonable standard, to uphold a patient’s right to life under Article 2 of the European Convention on Human Rights (ECHR) and his right to family life and his physical and moral integrity under Article 8. A patient’s family also has a similar right under the same Articles. The obligation to uphold a person’s rights encompasses a right to respect freedom of thought, conscience and religion (Article 9) and freedom of expression (Article 10) which would include the right to hold opinions and to receive information, and a right to be free from discriminatory practice in respect of these rights (Article 14).

That is not to say that a clinician must provide care at any cost. Where he believes it may be futile he need not provide it, even if the patient or his family demand it. Research suggests that only 20% of in-hospital attempts at cardio-pulmonary resuscitation (CPR) are likely to be successful. In this narrow respect, tensions can arise between a perceived need to maintain life and a professional’s view that there is more dignity in not doing so. In the context of a patient who is in the process of dying or who is at risk of cardiac arrest with little prospect of meaningful recovery, these tensions can frequently become more visceral. Where a DNAR notice is in place, caution is needed to avoid falling foul of the various legal obligations that pertain.

GMC guidance issued in July 2010 starts from a general assertion that if cardiac arrest is likely a management plan should be established in advance and a judgement should be made as early as possible about the likely benefits, burdens and risks based on the individual’s circumstances and the wishes of the patient. Any discussions should involve carers and family members as well as other healthcare professionals where it is appropriate to do so.

If CPR is likely to be unsuccessful, the healthcare professional should carefully and sensitively consider whether it is necessary to tell the patient, but should not withhold information just because it might be difficult to convey. If, for example, the patient does not wish to discuss or know about the consequences of an arrest or a decision not to resuscitate, the healthcare professional would be expected to seek authority to engage carers or family members. Obviously, the decision of a capable patient must be respected where this entails a choice to refuse treatment, but where no advance decision has been made (and in the case of life-sustaining treatment this should be in writing, signed by the patient and witnessed), once the patient arrests any decision must be in that patient’s best interests, applying the test required by s.4 of the Mental Capacity Act.

An advance decision does not allow a patient to demand CPR. That said, the UK Resuscitation Guidelines of 2007 suggest that the starting point where this issue has not been discussed is a presumption that CPR should be given. GMC guidance notes that where the benefits, burdens and risks are finely balanced, the patient’s request will usually be the deciding factor. If, after discussion with the patient, the healthcare professional still feels that CPR would not be clinically appropriate, he is not obliged to agree to attempt it. Reasons should be given and a second opinion offered.

That is not to suggest that the decision should be purely a clinical one. This point was strongly asserted by the family who challenged a DNAR notice in the recent case of R(Tracy) –v- Cambridge University Hospitals NHS Foundation Trust [2012] EWHC 3860 (Admin). In this particular case, the Judge, who was highly experienced in the law governing medical ethics, declined to make any statement of the law in this area. The issue is subject to considerable scrutiny currently, but GMC guidance is clear that even where a legal proxy insists on CPR but the clinician believes that it “would not be clinically appropriate and not of overall benefit for the patient,” it need not be provided.

UK Resuscitation Council guidelines adopt a similar approach, setting out a number of general recommendations. Decisions about CPR must be made on the basis of an individual assessment of each patient’s case.

• Advance care planning, including making decisions about CPR, is an important part of good clinical care for those at risk of cardio respiratory arrest.
• Communication and the provision of information are essential parts of good quality care.
• It is not necessary to initiate discussion about CPR with a patient if there is no reason to believe that the patient is likely to suffer a cardio respiratory arrest.
• Where no explicit decision has been made in advance there should be an initial presumption in favour of CPR.
• If CPR would not re-start the heart and breathing, it should not be attempted.
• Where the expected benefit of attempted CPR may be outweighed by the burdens, the patient’s informed views are of paramount importance. If the patient lacks capacity those close to the patient should be involved in discussions to explore the patient’s wishes, feelings, beliefs and values.
• If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable advance decision refusing CPR, this should be respected.
• A Do Not Attempt Resuscitation (DNAR) decision does not override clinical judgement in the unlikely event of a reversible cause of the patient’s respiratory or cardiac arrest that does not match the circumstances envisaged.
• DNAR decisions apply only to CPR and not to any other aspects of treatment.

Meanwhile, SHAs are expected to have policies on end of life care and DNARs. This inevitably gives rise to local variation in practice and policy, even between local Trusts. Given the need for sensitive management of such cases, a few additional pointers may assist:

• Consideration of a DNAR should always involve carers or family members where it is appropriate to do so; where the patient refuses to allow such involvement, this should be carefully recorded in the patient’s records
• Staff should be trained in the application of Trust policy on DNARs
• Any discussions about DNAR should be carefully recorded in the patient’s records
  • The reasons for implementing a DNAR decision should be carefully recorded in the patient’s records
• Any DNAR decision should be made subject to regular review

Further reading

• National End of Life Care Programme www.endoflifecare.nhs.uk
• Deciding Right www.theclinicalnetwork.org
• Decisions relating to cardiopulmonary resuscitation. A joint statement by the BMA, the Resuscitation Council (UK) and the RCN, October 2007
• Treatment and Care towards end of life: Good practice in decision-making, July 2010
• R(David Tracy) –v- Cambridge University Hospitals NHS Foundation Trust and others [2012] EWHC 3860 (Admin).