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

Prioritising people in nursing care.

There has been in recent years concern that care in the NHS has not been sufficiently 'patient centred', or responsive to the needs of the patient on a case basis. It has been felt in care that it as been the patient who has had to adapt to the regime of care, rather than the other way around. Putting patients at the centre of care means being responsive to their needs and supporting them through the process of health care delivery.  Patients should not become identikit sausages in a production line. The nurses body, the Nursing and Midwifery Council has responded to this challenge with a revised code of practice reflection get changes in health and social care since the previous code was published in 2008. The Code describes the professional standards of practice and behaviour for nurses and midwives. Four themes describe what nurses and midwives are expected to do: prioritise people practise effectively preserve safety, and promote professionalism and trust. The

When Finance Drives Destruction

Tackling climate change means stopping the funding of rainforest destruction, says a significant study commissioned by the World Wildlife Fund.  The UK's financial services have provided directly over £8.7 billion to 167 different traders, processors, and buyers of forest-risk commodities (cocoa, rubber, timber, soy, beef, palm oil, pulp & paper) from 2013 to 2021.   With direct and indirect investment,  the figure rises to a staggering £200 bn.  Whilst not all that investment is in destructive projects,  the study concludes there is little transparency on the risk.  Finance is the oil in the economic machine.  But it also drives decisions. We all know the importance of money. We borrow to invest. So much depends on it, such as company pensions.  Do we really know what our pension pots are doing? We invest for the future. But what kind of future? Is all investment good?  Much investment is bad. Investment drives the nature of our economy. It drives our decisions as individuals,