Judgement imposes legal duty to consult on DNAR decisions

A recent judgement by the Court of Appeal has confirmed that doctors have a legal duty to consult with and inform patients on DNAR decisions.  Guidelines issued for doctors already recommend patient and family involvement in DNAR decisions, but the court ruling now makes it a legal requirement.

The issue was first raised in 2012 in R (on behalf of David Tracey (personally and on behalf of the estate of Janet Tracey (Deceased)) v Cambridge University Hospitals NHS Foundation Trust and others.  The case was a judicial review against the Trust with regard to their DNAR policy and against the Secretary of State for failing to implement a national policy or procedure on DNAR.

The case concerned Mrs Tracey who had terminal cancer and had been given 9 months to live.  She had also just been admitted to hospital due to a car accident.  Her treating clinicians believed that it would not be appropriate for her to be resuscitated in the event of cardiac arrest.  Mrs Tracey died soon after and no resuscitation was given.

During her care at Addenbrooke’s Hospital two DNAR orders had been placed on her file.  The first was cancelled due to a lack of discussion with Mrs Tracey or her family and Mrs Tracey’s clear wish to receive CPR.  A second DNAR was placed on her file a few days later in consideration of the deterioration of her condition.

Her family pursued the case to seek clarity over DNAR orders and consent, due to the lack of consultation when the first DNAR order was issued.  The Court of Appeal has now ruled that doctors at the Hospital had acted unlawfully.

In the judgement, the Master of the Rolls, Lord Dyson, said “A Do Not Attempt Cardiac Pulmonary Resuscitation decision is one which will potentially deprive the patient of life-saving treatment, there should be a presumption in favour of patient involvement.  There needs to be convincing reasons not to involve the patient.” He warned that “Doctors should be wary of being too ready to exclude patients from the process on the grounds that their involvement is likely to distress them.”

Commenting on the judgement, Mrs Tracey’s husband, David Tracey said “We’re all so pleased that the Court has agreed that imposing a do not resuscitate order on Janet without consulting with her was unlawful.  It feels as though the wrong done to Janet has been recognised by the Court and the fact that her death has led to greater clarity in the law gives us all some small comfort.”

Dr Keith McNeil, the head of Cambridge University NHS Foundation Trust in charge of Addenbrooke’s said “Today’s ruling hinges on a specific point of law.  There was no criticism of our clinical care.  It is a fact of life that every day people die in hospitals.  From my own experience as a specialist hospital doctor, the most important thing is that these patients are treated with the utmost respect and dignity…End of life situations involve doctors and nurses having emotionally challenging but necessary conversations, with patients and their families about what happened in the final stages of their care.  Medical staff use a combination of their compassion, experience and judgement at these difficult times, to try and find the right pathway for each individual patient, and provide the support needed for everybody involved.”

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