Sunday, 23 December 2012

Do Not Resuscitate and patient care; who decides?

A family's legal action to force the government to review and adopt a clear policy requiring hospitals to consult patients and relatives before making "do not resuscitate" notices has been denied by a high court judge. Nevertheless, the case highlights inconsistency in approach to these orders between healthcare trusts and a lack of guidance in the training of doctors.

End of life decisions are never easy. Advances in medicine enable clinicians to resuscitate and keep patients alive in intensive care. But it can often bring two principles into conflict: the duty to preserve life and the duty to do no harm.  One might assume it is always better for a clinician to treat a patient; but to treat badly is not in the interest of the patient or of their close relatives. Sometimes it is better to withdraw treatment that seeks to combat illness and then to move to palliative care; to reduce pain, minimise suffering, and allow the patient to die peacefully and in dignity. When treatment becomes futile, then a clinician has a duty to acknowledge this and inform the patient and/or their relatives, and then to discuss what can be done.

What can be done depends on circumstances and the wishes of the patient. At any time, but particularly at this time, patients bring with them their 'expertise'; they bring their needs, their wishes, their relationships and obligations to their families. Each patient is in this regard unique.  And thus the patients are best placed to consider what they wish  with regard to what might be done. There is little in the training of a clinician that enables them to second guess the wishes of a patient. And this is why doctors should be wary of making assumptions about the best interest of their patient. 

This is why decisions about possible resuscitation should be made wherever possible with understanding and consent of the patient or their nearest relatives. Care should be taken about adding Do Not Resuscitate (DNR) to a patient's notes without proper consideration. This should only be done with clear understanding and consent. Where necessary this should be reviewed and updated. The patients condition and circumstances may change during treatment. The patient may also change their  mind about resuscitation in the light of these changed circumstances.  Thus, DNR should never be allowed to fester in the notes. But what this needs is a clear procedure. A clear protocol should be adopted to ensure DNR is reviewed and should never be assumed. 

This does not and cannot mean that the final decision on resuscitation will always rest with relatives. Where it would not only be futile but also harmful to resuscitate then that is a decision that can only be based on clinical judgement. But, whatever conflict DNR may bring for the clinician it is never as acute as that which it can present to the patient and their relatives.

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