Doctors Place DNR Notice on Patient's Notes Without Informing Her
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Angel of God, my guardian dear, to whom God's love commits me here, ever this day, be at my side to light and guard, to rule and guide. |
"Today's ruling hinges on a specific point of law. There was no criticism of our clinical care.How is making isolated and arbitrary decisions about whether they will live or die treating them with respect and dignity one wonders? Yes, these are always difficult situations, but the medical profession simply must always err on the side of caution, on the side of compassion, on the side of treatment, unless there are specific instructions to the contrary from the individual involved.
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."
Mrs Tracey, from Ware, in Hertfordshire, was suffering from advanced lung cancer when she was taken to hospital after a serious car crash. Her husband and daughters were distressed when a "do not resuscitate" notice was put on her hospital records. It was cancelled after the family complained, though a second was later put in place - after talks with the family and two days before Mrs Tracey died at the age of 63.
The case underlines a legal duty of NHS bodies to consult patients before making such DNR decisions, according to the family's legal team.
In the judgement, the Master of the Rolls, Lord Dyson, said the hospital trust violated Mrs Tracey's right to respect for her private life under Article 8 of the European Convention of Human Rights.
He 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 need to be convincing reasons not to involve the patient."Yeah, I'll say there do!! He went on to warn 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".One of the features of contemporary Western society is the tendency to evade the reality of death, to hide from it, to 'protect' people from it, almost to deny its reality until it is unavoidable. This tendency is connected to the 'practical atheism' noted by the Second Vatican Council (Gaudiem et Spes nn. 19-21), but the same Council document alerts the modern world to the need to confront the reality of death and to the yearnings for enduring life to which Christ alone provides an adequate response (Gaudiem et Spes nn. 18, 22).
Eternal life: 1 Cor 15:3-5, 12-20, 45-57 is in continuity with, but is not the same as our limited life on earth. Pope Saint John Paul II makes this truth explicit with a new expression for a Magisterial text in Evangelium Vitae. He speaks about human life "in its temporal phase" (n. 2:1) and "in its earthly state" (n. 38:3, 47:2). This points us towards another phase of human existence, namely eternal life, for which this current existence is a preparation. We, as Catholics, must hold to this metaphysical dimension to our understanding of the human condition. Life on earth is the condition for the attainment of all others. If we are not alive, we cannot pursue truth, aesthetics, justice, or salvation.
The care for the sick has become much more sophisticated and technological as time has gone on. A sick person can be isolated from family. Expertise and resources are needed to sustain the complex systems of care which sustain them, such systems are provided at a cost. It has become easier for not only the patient to feel a burden, but for nurses, doctors and others to see the patient as a 'case' or a 'problem' rather than as a person who retains their fundamental dignity despite all the dependence and weakness. This is further confounded by the subjective way in which increasing numbers in the medical profession ridicule theism.
The dignity of each person must be respected as we are all created in the image and the likeness of God. This also has implications for how the patient is treated. As Catholics, we may refuse extra-ordinary treatment, what is likely to be futile or unduly burdensome (e.g. an operation with very limited hope of success, when the general medical state of the patient is considered. If it is honestly judged that any benefit would be only marginal and that the disruption to them would be major, then the means are extra-ordinary and are not obligatory.
Nutrition and hydration are not extra-ordinary, or even forms of therapy. They are a fundamental human need and should be provided to people who are untreatable, as part of the care to which all are entitled. Informed Consent is not a just legal or procedural requirement; it is a moral one.
I am totally with you as regards informing the family; secret and sneaky decisions about matters of life and death are anathema and not to be tolerated. That is the aspect of this which is frightening.
ReplyDeleteA DNR notice, as such, need not be. I was somewhat perturbed when my sister rang me one evening to ask if I would agree with the suggestion of our GP that we should put a DNR notice in my mother's notes. It was obvious she was on the finishing straight of life, although the chequered flag might be further off than we feared. Having heard such stories as you relate here, I queried it. My sister explained that in the absence of such a notice, if she were to collapse at home and an ambulance be called, they would be obliged to resuscitate, which would involve applying a shock to her heart; this very rarely worked and caused distress to both the patient and anybody who saw the procedure.
Given that information I was happy to consent. She had a weak heart, and either that or a fall at home could have resulted in us calling an ambulance; resuscitation might not have been appropriate, given her heart was already weak, but they would have been obliged to attempt it, which would have been an intervention too far.
Thanks for this post Mark - it was very thought-provoking. I think it really brings out the ethical aspect to this case, though there are a few bits I disagree with you slightly on and some things I think need to be explored a bit further.
ReplyDeleteWhen you say the medical profession must err on the side of caution and of compassion - which of course I agree with - and that DNACPR decisions are decisions about 'whether someone will live or die', I think it's worth noting that only 30% of CPR attempts are successful, and only 12% of those patients who have undergone and survived CPR are then discharged from hospital alive. CPR is in most cases the 'futile or unduly burdensome' intervention described in the catechism as extra-ordinary.
The other thing is that, at the end of the day, whether or not to attempt CPR is a clinical decision - though of course our human dignity necessitates that we be informed of this decision if we have the capacity to be, and we can seek a second opinion if we want. And that's what the issue was in this case: it was the communications process surrounding the decision to make the order, not the order itself. I don't think Dr McNeill's observation that clinical care offered at Addenbrooke's was not under dispute is as much of a fudge as you seem to think.
It was clearly wrong, given she had expressly said she wanted to be consulted about her care, that Mrs Tracey wasn't made aware of the DNACPR order. That doesn't mean the DNACPR itself was wrong. Doctors shouldn't, and don't, have any obligation to put a patient through an intervention they know is likely to be futile because he or she has expressed a wish for it.
Of course it is important to talk this decision through with the patient and their family *if possible*, and that's already part of best practice guidelines. There are issues around enshrining this in law though. When you talk about erring on the side of caution, I think it's worth noting that we can talk of both *legal* caution and of *medical* caution. Erring on the side of legal caution might mean not putting a clinically justified DNR order on a dying patient just in case their family kick up a fuss later, thus meaning he or she has to go through a distressing (and CPR can be VERY distressing) and ultimately futile intervention. For a lot of patients, the opportunity for the clinician to sit down with them and/or their family and have the DNR conversation doesn't come up - for example, due to the speed of their deterioration.
Obviously this is all speculation from me but I think there's a pretty complex ethical dilemma here about the relationship between patient choice and clinical best practice can collide.
On which note I better get back to work but thank you again for putting this case in its ethical context!
Megan
Good grief, I've just realised this is nearly as long as the post itself. Sorry...!
DeleteI think the issue is not so much that they made a decision not to resuscitate, which as you point out is a clinical one, but that they placed a DNAR in her record without her consent. Healthcare professionals are required to respect the right of their patients to make decisions about their own treatment. Maybe if it had been discussed with her she would have agreed that a DNAR was an appropriate idea (and from the fact that after discussion with the family, the DNAR was reinstated it's quite possible that this might have been what the patient decided), the point is that this did not happen. On the other hand, I know of a terminally ill, dying patient who recently died and despite the fact that there was a DNAR on file, resuscitation was attempted (I heard that this is because the copy in his notes was a photocopy and not the original). The patient died anyway.
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