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Mr Robert Wheeler

Do not attempt cardiopulmonary resuscitation

On these pages I discuss the clinical law on which our nursing and medical staff rely when caring for our patients.

Mr Robert Wheeler, director, department of clinical law

On 17 June 2014, the Court of Appeal handed down its judgement in the case of Mrs Janet Tracey. This made clearer the process that all clinicians in the NHS should follow when deciding whether a do not attempt cardiopulmonary resuscitation (DNACPR) decision should be made for a patient.

The court found that a DNACPR notice was placed in Mrs Tracey's notes without consulting either her or her family. Mrs Tracey's family were not complaining about the decision to withhold CPR. Rather, about the procedure leading to the decision to withhold it.

The DNACPR decision is important since it concerns a person's choice as how to pass the closing days and moments of his/her life, and how they manage their death. The patient's wishes in these matters are an expression of their right to determine their own destiny; in other words, their autonomy.

The court decided that the presumption is that all patients should be involved in decisions concerning DNACPR. There would need to be convincing reasons for not involving the patient in this process. The court recognised that a patient who is contemplating the end of his/her life is likely to be distressed by discussions concerning a DNACPR decision. But that their distress on its own is not a convincing reason to allow the clinician to avoid having this discussion. However, if the clinician believes that the discussion will lead to physical or psychological harm for the patient, then that would be a convincing reason to refrain from discussing the DNACPR decision.

The court found that if a clinician considers that CPR will not be effective, he/she is not under an obligation to provide it, and the patient cannot require them to do so. But the presumption is that the patient is still entitled to know that the clinical decision of DNACPR has been made, and to have been involved in the discussions that led up to the decision.

In summary, the judgement establishes a duty; that we must consult patients in relation to DNACPR decisions, unless the clinician believes that the distress that will be caused by the discussion will harm the patient. In the circumstances when we avoid the consultation because we believe that harm will be caused, we must document our reasons for this belief. If the patient lacks capacity, we must take reasonable steps to involve the patient's family in the discussions that lead to a decision as to whether or not it is appropriate to attempt cardiopulmonary resuscitation.