The continuing challenges of Do Not Attempt Cardio-Pulmonary Resuscitation orders

Having previously written about compassionate paternalism in the context of end of life care and Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)(Spearpoint, 2014) it was disappointing to read of yet another case in the media spotlight that highlighted the apparent inadequacies of communication skills by medical professionals.

The recent case reported on the BBC News appeared to highlight the considerable limitations of the medical gaze with regard to prioritising the difficult conversations with vulnerable patients and their families that accompany DNACPR decisions.

In a case that mirrors a complaint that was upheld by the health service ombudsman some 24 years ago (Department of Heath, 1991), the family of the patient considered that they had not been made aware of the placement of a DNACPR order, which was something that they discovered 4 days after his death (http://m.bbc.co.uk/news/uk-england-norfolk-31906905).

Since the publication of the first directive from the Chief Medical Officer (Department of Heath, 1991) a series of national guidance documents regarding DNACPR have been (jointly) issued by Royal College of Nursing, The British Medical Association and the Resuscitation Council UK, which were accompanied by a succession of policy upgrades by hospital Trusts.

However, the situation regarding effective and timely communication with patients and their family members continues to provide healthcare professionals with a significant challenge and it is one that contains a considerable paradox. Failure to comply with established law and the associated medico-legal guidelines leaves both the patient and the medical practitioner vulnerable.

It is my experience, that when discussing the difficult issues that surround DNACPR with medical colleagues they almost always appear entirely conversant with the medico-legal position and more than capable of making a confident, guidance / policy compliant decision that is in the best interest of the patient. Such an example is provided here in Phil Berry’s insightful and thoughtful blog.

> https://illusionsofautonomy.wordpress.com

But something happens that makes intelligent, articulate professionals take unnecessary risks when faced with a patient, their family and that DNACPR order.

At that exact moment is the pressure of work and the clinical environment prohibitive to the provision sensitive, compassionate information of this nature? Does the nature of the situation over-ride the usual assured confidence of discussing the advanced care plan with the patient? Are these medical professionals appropriately trained and experienced in conducting difficult conversations? Are patients and relatives given time to contemplate the enormity of the DNACPR decision? Is the patient given permission and time to think it through, discuss it with their loved ones or discuss it with other healthcare professionals? Does the paternalistic culture of the medical gaze come to the fore?

Whatever the situation, the medico-social and culturally determined human factors issues identified above need to be more fully understood in order to inform our thinking towards developing a better, patient-centred approach to this problematic continuum.

By way of a post-script regarding the case in question, it was interesting to note that the coroner considered that the doctors had acted in accordance with local hospital policy guidance http://m.bbc.co.uk/news/uk-england-norfolk-31941596, a situation that appears to continue to support compassionate paternalism.

References

Department of Health (1991). Letter from the Chief Medical Officer to all consultants on resuscitation policy, dated 20.12.1991. PL/CMO (91) 22.

Spearpoint, K. (2014). Compassionate paternalism and the Janet Tracey judgment. International Journal of Palliative Nursing. 20(1). 369.

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One thought on “The continuing challenges of Do Not Attempt Cardio-Pulmonary Resuscitation orders

  1. Hi Ken,

    Thanks for referencing my blog. The essential difference in our positions may be encapsulated in your sentence – ‘Are patients and relatives given time to contemplate the enormity of the DNACPR decision?’

    In my blog post ‘Beyond the implicit’ I try to explore how CPR is, in the context of expected death from terminal illness, a medically irrelevant intervention that should not become the focus of a prolonged discussion or an agonised thought process. However, because it is a symbol of transition and of a person’s last chance to ‘fight’ death, it has acquired a very powerful status in end of life considerations. I worry that the phrase ‘enormity of the DNACPR decision’ compounds this. In expected death the decision not to perform should be implicit in end of life plans, not enlarged into dissociated subject.

    However I recognise that my view, and that of other doctors hardened to the inevitability of death in certain disease processes, does not necessarily afford sufficient respect to patients’ need to consider and take ownership of this decision. This is the problem. For a doctor the question of CPR may seem so academic, in terms of efficacy, as to appear unworthy of discussion; for the patient it is a conversation about their last minutes of biological activity on earth.

    Therefore, my view is that forcing ourselves (or being forced by law now) to open up that conversation is actually an exercise in empathy, in understanding how terminally ill people need to be to given the opportunity to discuss the manner of their death, rather than an exercise in pertinent medical decision making. That is fine, we should learn to deal with that. The risk is that on those occasions when we don’t manage to do this, or cannot due to a patient’s inability to talk or lack of time to contact next of kin, we are criticised or, even worse, taken to court.

    Phil

    Like

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