At Ridouts, we have noticed increased scrutiny on the part of the Care Quality Commission in relation to end of life care, of which DNAR decision-making is a key element. In our experience, there is often a lack of awareness about the requirements that need to be followed by practitioners in relation to DNAR decision-making in healthcare settings. In this regard, the BMA, RCN and Resuscitation Council have recently updated their guidance on Decisions relating to cardiopulmonary resuscitation which practitioners will be expected to have regard to in relation to DNAR matters.
We have seen cases where a DNAR Order has been put in place without a proper assessment being undertaken of the patient. In addition, problems can occur when doctors place DNAR Orders on the files of patients without having consulted family and significant others. This can lead to complaints and potentially legal challenges for failure to comply with Mental Capacity Act requirements. The courts have upheld the requirement to consult family members where the patient does not have capacity to participate in the process leading to the DNAR decision.
Key practical points aimed at securing compliance with end of life decisions relating to cardiopulmonary resuscitation (CPR) include the following:
- Does the patient have capacity? If they have capacity, they can refuse CPR and this would need to be documented and respected.
- If the patient does not have capacity, is there an advance decision refusing CPR? If there is a valid and applicable advance decision in place this must be respected.
- The person making the best interests decision about CPR on behalf of an incapacitated patient user (normally the GP) will need to follow the “best interests’ checklist” set out in section 4 of the Mental Capacity Act. In particular, the decision-maker will want to consult other healthcare professionals, relatives and significant others (including anyone who is operating under a Lasting Power of Attorney or who is a court appointed deputy) to inform the eventual decision. This will be particularly important if any decision about CPR is balanced. However, the doctor should consult family members, and any persons properly concerned with the welfare of the patient, even if there is no clinical reason for undertaking CPR given the importance of ensuring that everyone is clear that CPR will have no clinical benefit for the patient.
- Consideration should be given to whether a DNAR Order needs to be reviewed. In the context of an acute illness one can contemplate regular reviews in response to a patient’s changing condition but for end of life care there may be no need to review the decision if the situation is irreversible.
- Decisions should always be made on the basis of the particular patient’s condition; a blanket approach is never acceptable.
At Ridouts, we have considerable experience of advising on end of life care issues, including reviewing policies and procedures. Please feel free to contact us.