Clinicians and Relatives, Consensus, Uncertainty, Emergency and Trust: a continuation from a Journal of Medical Ethics paper

mike stone 02/10/21 Dignity Champions forum

Clinicians and Relatives, Consensus, Uncertainty, Emergency and Trust: a continuation from a Journal of Medical Ethics paper

I was one of the authors of a paper titled ‘Family members, ambulance clinicians and attempting CPR in the community: the ethical and legal imperative to reach collaborative consensus at speed’ which was published by the Journal of Medical Ethics in 2020:

The paper discusses a scenario when a wife phones 999, and her husband’s heart stops beating while the 999 Ambulance is en route to her home – the paramedics start cardiopulmonary resuscitation (CPR) and the wife promptly objects:

‘She reiterated that the 999 call was due to a seizure, and had it been for the purpose of providing resuscitation, she would not have called the emergency services ...’

In our paper, we did not discuss the issue which that sentence raises – that if the wife thought her husband’s heart had stopped, she would never have called 999 until after her husband had died: in the paper, we only discussed how a 999 paramedic decides whether or not to attempt CPR once the paramedic has become involved.

The issue raised by that sentence in our paper, is similar to the issues raised by my ‘Father and Son’ scenario:

The PDF discusses this issue – what happens, or "should happen', if a family-carer or relative knows a loved-one should not be resuscitated, but believes that if 999 are summoned to confirm the cardiopulmonary arrest, the paramedics would probably attempt CPR.

Associated files and links:

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mike stone 05/01/23

I have attached a PDF which contains an e-mail I sent to some coroners, and some of their more helpful replies, after I had been talking to a Paramedic at a Coventry University Open Day - as I stated in my e-mail:

'I was recently talking to a Paramedic at a Coventry University open day. It was a brief conversation, during which he said what amounts to 'I would never accept a relative's word that the patient wouldn't want CPR - I would always [if it appeared that CPR might be clinically successful] attempt CPR unless there was documentation'. He also said, that he believed he would be in trouble with the Coventry Coroner, if he did believe the word of a relative.'

So, I asked the coroners 'are coroners effectively telling 999 paramedics, that paramedics should not believe what relatives say to them?'.

To quote the clearest reply from a coroner - and this was fairly-obviously true, but I wasn't confident that a coroner would state it for me:

'It is not within the coroner’s remit to advise paramedics how they should approach their professional practice'.

Put simply, it isn't within the remit or authority of a coroner to 'order 999 paramedics to distrust family-carers and relatives'.

Associated files and links:

mike stone 09/09/23

In the Journal of Medical Ethics paper I contributed to,

which was narrowly about the decision-making for cardiopulmonary resuscitation (CPR) but more generally about any treatment, and what the Mental Capacity Act tells us about decision making, I included the sentence

'Put simply, the clinicians are the experts in the clinical aspects, and the family and friends are the experts in ‘the patient as an individual’'

That sentence should be a good starting point, for anyone who is involved in discussions about what would be in a patient/loved-one's MCA Best Interests.

Doctors and nurses, typically write - to my great annoyance! - as if 'doctors make the best-interests decision, and family and friends ('those close to the patient') only contribute to the decision-making of clinicians'. That isn't true legally - the issue is the 'only'. That 'only' will often be true, but it isn't necessarily true.

We should regard these conversations about best interests, as involving TWO DIFFERENT TYPES OF EXPERT in conversation with each other: the clinicians are experts in the clinical situation, what treatments are available, and prognoses, and the family and friends are experts in 'the patient as an individual'. The objective of the conversations is to apply section 4 of the MCA in order to arrive at properly-considered best-interests determinations. That necessarily involves a third type of 'expertise or understanding', which is an adequate understanding of the MCA: a LEGAL understanding, which is neither the type of expertise specific to the clinicians, nor the type of expertise specific to 'those close to the patient'.

We have, when thought of in this way, two different groups of experts, the knowledge and understanding of both groups being necessary to properly achieve an objective which requires a third type of understanding (an understanding of the MCA) - and, that third type of understanding is not an understanding which is necessarily solely possessed by either group of experts.

Viewed in this light, those close family and friends who DO UNDERSTAND the MCA, should RIGHTLY take offence if clinicians say 'you need to understand, that YOUR role is only to inform OUR decision-making'.

In my opinion, it is high time for this to be reflected within the thinking of clinicians: that 'those close to the patients' should be regarded as EXPERTS.

As we also suggested in the JME paper:

'The guidance and the training should emphasise the teamwork which Mike Stone mentions above: the default assumption should be that clinicians and relatives have a shared goal of what is best for the patient, and work together as ‘us and us’ as opposed to ‘us and them’.'

PS In fact there is a typo in the paper - it says 'teawork' instead of 'teamwork'. I quite like that typo - perhaps there should be 'teawork' involved during the teamwork!