But reading that as a patient or family carer ...
I was sent some of my local end-of-life documents last week, and I am in the process of discussing these with various Mental Capacity Act contacts. I am also going to discuss them here.
I will post the discussion here in stages, and the PDF I am writing about can be downloaded from:
http://www.c-a-s-t-l-e.org.uk/media/18187/final_dnacpr_policy_v_2.0.pdf
I will number these, as 'Discussion Point 'x''.
DISCUSSION POINT 1
On page 12 of the PDF, you can find this:
8.1 Making a DNACPR decision for a patient who lacks capacity
A decision that CPR will not be attempted on best interests grounds, should only be made after careful consideration of all relevant factors, and after discussion with those close to patients who lack capacity. In situations where a patient lacks capacity and staff are unaware of any Advance Statement (including a valid and applicable ADRT to refuse CPR), then a further check must be made to identify if the patient has appointed a Lasting Power of Attorney for welfare.
If the patient lacks capacity and has appointed a welfare attorney, whose authority extends to making these clinical decisions, or if a court has appointed a deputy or guardian with similar authority to act on the individual's behalf, this person should be informed of the decision and
the reason for it. If a second opinion is requested, this should be arranged whenever possible.
In situations where a patient lacks capacity, no Advance Statement (including a valid and
applicable ADRT to refuse CPR), no welfare attorney appointment and no appropriate family, friends or other advocate to consult, then it is strongly recommended that a referral to the Independent Mental Capacity Advocate (IMCA) service be made. This however does not apply in the emergency situation where a patient's death is imminent. See Appendix C for further information on IMCA referral.
MY COMMENTS:
1) We MUST be talking about a situation 'when CPR might be successful in restarting the heart' - BECAUSE the piece starts by talking about 'A decision that CPR will not be attempted on best interests grounds';
2) The above points out that there might be a welfare attorney whose authority extends to making the CPR decision - if that is the case, then the welfare attorney would make the decision and tell the clinicians what the decision was. This piece doesn't say that - it says the clinicians should inform the welfare attorney of the decision (which isn't a decision the clinicians should be making !);
3) It is wrong to describe any decision which a welfare attorney possesses legal authority over, as 'a clinical decision' - this describes attorneys as possessing powers over 'clinical decisions' and people MUST stop writing such nonsense (because many clinicians understand the MCA very poorly, and such 'inappropriate language' simply adds to the confusion);
4) An 'advance statement' CANNOT 'include an ADRT which refuses CPR'. An 'advance statement' is something which a person making an MCA best-interests decision would need to consider: but a valid and applicable ADRT REMOVES THE NEED FOR best-interests decision making. So an ADRT forbidding CPR, CANNOT BE 'part of an 'advance statement''. There is 'shambolic conceptual mess' developing around these 'advance statements' at the moment, to my great annoyance !;
5) It is NOT POSSIBLE for a Court Deputy to have 'similar authority' to a Welfare Attorney whose authority extends over CPR - the LAW ITSELF FORBIDS A COURT from giving a court deputy authority over life-sustaining treatments.
QUESTION: does anybody ACTUALLY READ AND THINK ABOUT THE MCA before writing this rubbish ?!
DISCUSSION POINT 2
On page 5 of the document, you can find:
'Some patients who have capacity may wish to make an Advance Statement about whether or not they would accept CPR if this was a treatment option.
A valid Advance Decision to Refuse Treatment (ADRT) to document refusal of CPR must be respected as long as these decisions are informed, current and made without coercion from others. If a patient has requested to refuse CPR then the Coventry & Warwickshire DNACPR form must be completed as per this policy.'
The C&W DNACPR form can be found on page 23 of the document - the significant point, is that the DNACPR form does NOT have a space for the signature of either the patient, or of any welfare attorney whose decision-making authority extends over CPR.
I wrote about the difference between a written ADRT refusing CPR, and a 'DNACPR form' [signed only by a clinician] in my piece at:
http://www.bmj.com/content/350/bmj.h2157/rr-1
I also recently pointed this wording out to one of my contacts, who leads on the MCA for a well-known 'healthcare organisation', and got back the comment:
'I start out by thinking, however, that it might be a good idea to record on a DNACPR recording form that a person has made a valid ADRT refusing CPR: this could be very helpful for, say, paramedics and in a confused situation, in that it gives, possibly, junior staff the confidence to obey the ADRT and recognise its legal force. (I've often encountered the argument that the attending clinician may know nothing about the lawfulness or genuineness of any document they're shown, which can lead to risk-averse, rights-averse practice). So it's using the form to provide evidence that the ADRT exists and that, at least at the time of writing on the form, the person hadn't rescinded it. This isn't of course a lawful requirement, and shouldn't be necessary, but until some emergency clinicians get more used to ADRTs and honour them better, I don't mind them being given this confirmation.
But you have identified some confusion in the terminology all right. Unless they've moved on to a situation where an individual with capacity is currently refusing CPR, which is a perfectly possible scenario, it does risk appearing as though the ADRT is being treated as having the status simply of a request.'
A written ADRT refusing CPR, signed by the patient and witnessed by a lay person, is a legally-binding document - but a DNACPR form signed only by clinicians, is something quite different [and is almost never in any sense 'a legally binding document'].
So my correspondent's 'This isn't of course a lawful requirement, and shouldn't be necessary, but until some emergency clinicians get more used to ADRTs and honour them better' gets to one core point.
There is another issue, especially if the patient is at home, and is fairly healthy. A patient can in theory use a written ADRT to forbid CPR despite a cardiopulmonary arrest being unlikely, and when the resulting death could not be certified. It is simply not possible for the relevant doctor - who would be the GP - to write anything at all, beyond 'this patient HAD an ADRT refusing CPR when he told me about it 'date''. The GP cannot know if the patient has subsequently retracted the ADRT until the patient tells the GP, and this is a fundamental problem if you want to refuse CPR at home - see my 'Alan and Liz' scenario in my piece at:
And also see 'Father and Son' (poser no 11) in my piece at:
DISCUSSION POINT 3
On page 4 of the document we are informed:
'This policy and accompanying literature is based on current
national guidance produced by the British Medical Association (BMA), Royal College of Nursing (RCN) and Resuscitation Council (UK)'
Yes, I had noticed.
The question is whether the guidance currently issued by the BMA/RCN/RC(UK) is legally correct and 'perspective-balanced'.
My position is that the BMA/RCN/RC(UK) guidance is flawed.
And if the BMA/RCN/RC(UK) guidance is not in line with the law, then that guidance is 'encouraging clinicians to act illegally' - which cannot be right.
It is very difficult indeed, to 'argue about the correctness of high-level guidance'.
DISCUSSION POINT 4
Also on page 4, we can find:
'Health and social care professionals are aware that decisions about whether to attempt cardiopulmonary resuscitation (CPR) can raise emotive and distressing issues for both patients and those that have an emotional attachment to them. Some health care professionals
may not find it easy to discuss CPR decisions, but this must not prevent discussion, either to inform a patient of a decision or to involve a patient in the decision making process where appropriate. It is best practice to include patients in the decision making process and to inform
patients of any decision made. However discussion about CPR should not be forced on patients who
indicate that they do not wish to discuss this topic. This is supported by professional guidance such as
that is provided by the General Medical Council and Nursing
and Midwifery Council.'
Professor David Oliver recently wrote an article for the British Medical Journal, and he thinks that some recent court rulings which have stressed that doctors must discuss CPR with patients, will actually lead to LESS AND WORSE discussion of CPR. See Professor Oliver's piece (a response to the responses to his original article) at:
http://www.bmj.com/content/352/bmj.i1494/rr-4
QUICK COMMENT:
I AM 'making the posts look right in the submission boxes' - some text 're-formats' (such as the post above) after I've checked it looks right before I click on 'submit', and it looks fairly awful once posted.
There is no way, for me to prevent that from happening, so far as I can see.
DISCUSSION POINT 5
DISCUSSION POINT 6
This appears at the bottom of page 7, and I'm less than happy with this sentence, but it would take me too long to explain exactly why !:
The individual should inform where able, those caring for
them that there is a valid documented DNACPR decision about themselves and where this can be found.
This is on page 8:
5.4 Consultants / General Practitioners are responsible for
making DNACPR decisions
No, they are not - consultants and GPs are not responsible for making:
1) an MCA Advance Decision to refuse CPR - the patient is the only person who makes that DNACPR decision;
2) if a welfare attorney has been given decision-making authority over CPR, then the decision that it is in the patient's best interests that CPR should not be attempted is the welfare attorney's decision: it is not the consultant's, or GP's, decision.
Forgot to label the previous one - anyway, the previous one and this one, can together be thought of as Discussion Point 7.
This appears on page 9:
'Neither patients, nor those close to them, can demand treatment that is clinically inappropriate. If the healthcare team believes that CPR will not re-start the heart and
breathing, this should be explained to the patient /patient's family in a sensitive way'
THAT is what consultants and GPs ARE responsible for - they are the clinicians best-qualified to express an EXPERT CLINICAL OPINION about the likely 'success' of a future CPR attempt. Which isn't the same things as a decision that CPR should not be attempted, and it DEFINITELY IS NOT the same thing as 'best-interests decision-making' [when CPR might potentially re-start the heart].
See, for example, my piece at:
DISCUSSION POINT 8
I think things are now starting to be repeated.
On page 10:
'6.2 Refusals of CPR by Adults with capacity
In these circumstances a DNACPR decision will be made. Assessing Capacity Appendix C'
Sorry, NO ! 'In these circumstances a DNACPR decision HAS BEEN MADE' - if the patient has capacity, and the patient has refused CPR, THEN THE DECISION HAS BEEN MADE !
See for example:
http://www.bmj.com/content/351/bmj.h6575/rr-0
And the MCA says that until 'proven incapable' patients ARE ASSUMED mentally capable.
DISCUSSION POINT 9
Also on page 10:
'6.3 The overall clinical responsibility for decisions about CPR
Responsibility for DNACPR decisions rests with the most senior clinician in charge of the patient's care as defined by local policy (See Appendix D Link 1 section 13)'
NO - WRONG ! See DISCUSSION POINT 7 above.
I'm not labelling this one, but page 10 goes on to 'In the Community setting' and it is again wrong, for exactly the same reasons - it is confusing the issues of clinical expertise and legal authority over the decision-making for CPR, and it compounds this confusion by muddling together the decision-making and the decision-sharing necessary for competent joined-up behaviour.
DISCUSSION POINT 10
On page 11 we can read this (which is better than usual in terms of its 'as certain as it can be'):
'If the medical team is as certain as it can be that CPR would not have a medically successful outcome it is inappropriate to offer it as a treatment option.'
However, it is possible to construct a scenario when CPR clearly should be attempted ONLY IF YOU WERE 100% CERTAIN THAT CPR WOULD BE UNSUCCESSFUL.
You will find the scenario, and afterwards (in my post at 17/08/14 - 13:18) my reasons for constructing it, in my post at 18/05/14 - 12:14 in my 'poser series' at:
I also dislike these 'clinical DNACPR decisions' - I much prefer for patients to have forbidden attempted CPR:
http://www.bmj.com/content/350/bmj.h2640/rr-2
There is a typo in that BMJ piece:
'... when something ca[u]ses an arrest ...'