Skip to main content

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.

Comments

Popular posts from this blog

Ian Duncan-Smith says he wants to make those on benefits 'better people'!

By any account, the government's austerity strategy is utilitarian. It justifies its approach by the presumed potential ends. It's objective is to cut the deficit, but it has also adopted another objective which is specifically targeted. It seeks to drive people off benefits and 'back to work'.  The two together are toxic to the poorest in society. Those least able to cope are the most affected by the cuts in benefits and the loss of services. It is the coupling of these two strategic aims that make their policies ethically questionable. For, by combining the two, slashing the value of benefits to make budget savings while also changing the benefits system, the highest burden falls on a specific group, those dependent on benefits. For the greater good of the majority, a minority group, those on benefits, are being sacrificed; sacrificed on the altar of austerity. And they are being sacrificed in part so that others may be spared. Utilitarian ethics considers the ba...

Ethical considerations of a National DNA database.

Plans for a national DNA database   will be revealed by the Prime Minister this week. This is the same proposal the Tories and Liberal Democrats opposed when presented by the Blair government because they argued it posed  a threat to civil liberties. This time it is expected to offer an 'opt-out' clause for those who do not wish their data to be stored; exactly how this would operate isn't yet clear. But does it matter and does it really pose a threat to civil liberties? When it comes to biology and ethics we tend to have a distorted view of DNA and genetics. This is for two reasons. The first is that it is thought that our genome somehow represents the individual as a code that then gets translated. This is biologically speaking wrong. DNA is a template and part of the machinery for making proteins. It isn't a code in anything like the sense of being a 'blueprint' or 'book of life'.  Although these metaphors are used often they are just that, metapho...

Work Capability Assessments cause suffering for the mentally ill

People suffering from mental health problems are often the most vulnerable when seeking help. Mental health can have a major impact on work, housing, relationships and finances. The Work Capability Assessments (WCA) thus present a particular challenge to those suffering mental illness.  The mentally ill also are often the least able to present their case. Staff involved in assessments lack sufficient expertise or training to understand mental health issues and how they affect capability. Because of  concerns that Work Capability Assessments will have a particularly detrimental effect on the mentally ill,  an  e-petition  on the government web site calls on the Department of Work and Pensions to exclude people with complex mental health problems such as paranoid schizophrenia and personality disorders. Problems with the WCA  have been highlighted in general by the fact that up to 78% of 'fit to work' decisions are  being overturned on appeal. I...