Coronavirus and DNAR

The press are reporting that GPs are intensifying requests/ demands/ advice about the signing of “expressions of wishes”/ advance directives as to advance consent by a patient to staff not attempting resuscitation of patients some but not all of whom may be receiving end of life care.

This is a difficult and sensitive area. It is most certainly not a routine form filling exercise. First the issue is not of general application, but, where following cardio-pulmonary malfunction, attempts are made to restart cardiac activity usually accompanied by a moderate to severe degree of direct violence which is needed in the circumstances.

It is not a general licence to deliberately or negligently withhold patient’s life savings treatment. In the cases of the frail and of older people the violent needed may be unjustified and may prospectively cause life threatening injury.

Second, the consent is not to fail to resuscitate but rather not attempting resuscitation at all. Whether or not such an attempt is made is a matter of the clinical judgement of the practitioner engaged. The practitioner will only act if there is a prospect of success and a beneficial outcome.

A DNAR consent may not even be effective at all. Capacitous people often change their mind when faced with actuality as opposed to theory.

For a capacitous patient, such a consent/ advance directive is only valid if demonstrated to have been executed in full knowledge of all the circumstances and risks. It must be a free decision of choice or having considered surely all relevant information. Where the patient is assessed as lacking capacity then arguably it is not appropriate to prepare and complete a DNAR in advance under any circumstances. At the very least, there must be an urgent “best interests” decision when the crisis arises with all concerned and the decision based upon what the patient would have decided if capacitous. A very recent case in the Court of Protection ruled that it could not be in the patient’s best interest to be starved of life. COPD resuscitation is more dynamic than that. So called DNAR RMS should never be completed without reference be the patient or a full best intents decision and certainly not simply slipped into patient’s files.

Clinicians and carers are in a very difficult position but must not feel pressured into completing such “opinions” for the administrative convenience of others. They must also not go beyond their professional technical expertise.

Death which results from a failure to act is just as unlawful as death caused by an action, if either the failure or the act are not sanctioned by the law that may be categorised as neglectful or even criminal. The existence of a DNAR “consent” may actually encourage an unlawful act with the wrong impression that the DNAR justifies the event. It does not, unless fully and properly completed with full knowledge of relevant information and that the consent remains valid when the decision is to be made.

Care providers and their staff should exercise extreme caution when being pressured to provide a justification for negligent actions which may well turn out to be unlawful.