The documentation of DNACPR decisions.
Recently there has been a heightened interest in DNACPR decision-making and DNACPR documentation. There is also what I will term 'confusion' about whether it is possible to create a DNACPR document today, which would instruct a clinician reading it next week, to not attempt CPR. I have analysed and discussed this, in the PDF.
Associated files and links:
We Decide in the Now
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I have spotted a couple of mistakes in the PDF.
On page 4 it should NOT mention the 'Montgomery' ruling - it should have said 'The clearest ruling on this is the 'Briggs' ruling'. I had been thinking about the Montgomery ruling in a different context - that was 'a slip of the brain'.
On page 3 at one point I wrote 'can we' when the sentence requires 'we can' (I had in my head 'Only when everyone agrees it should be DNACPR can we usefully document ...' but I wrote a different sentence).
I do not consider that those two mistakes alone, justify my uploading a corrected version of the PDF, as I think they do not destroy the sense of the piece [although some readers will be thinking 'where did Montgomery come ftom?!]. I might at some point upload a longer version of the piece, which incorporates corrections of the above mistakes.
This is a version of the PDF which has been corrected, and also expanded a little to show some wording from the NHS website.
Associated files and links:
We Decide in the Now version 2
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The piece I wrote recently at
is also relevant to this discussion.
In the previous PDF/s I have posted in this thread, I have mentioned a 'best-interests meeting' which is going on in a room, but I did not describe the conversation during the BI meeting. In this PDF, I consider the actual best interests discussion itself, and I mention an issue around 'and who should be present in the room'.
In passing, I will probably be adding a further addition to this thread, asking 'how does medical ethics fit, inside that room'. Indirectly, the PDF attached, might be seen as implying my own 'answers' to the question of how medical ethics fits into MCA best-interests decision-making.
Associated files and links:
What should happen at an MCA Best Interests Meeting
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I might expand on this, in a PDF which I will write and upload to this thread at some future date. So I present an 'outline" here.
It has been put to me, that 'Medical Ethics' has a part to play during MCA Best-Interests decision-making. Pethaps it does - I am honestly not sure what the assertion actually amounted to. The person who introduced medical ethics into our discussion, suggested that my suggestion that medical ethics shouldn't really have much of a role in best-interests decision-making, implied that I did not want all available knowledge to be used during best-interests decision-making. My position, could be described as 'I want all of the RELEVANT information and expertise, WHICH IS ACTUALLY AVAILABLE, to be utilised during best-interests decision-making'.
At the moment I am trying to discuss a particular problem 'with the NHS', and to 'resolve it' - I am not sure how medical ethics can be used to address this problem, and myself I use proportionality, logic and perspective-balance. The problem is this.
The following problem is what I believe a recent Journal of Medical Ethics paper I contributed to implicity raised - and I have been discussing this type of scenario, and the interactions between 999 paramedics and relatives, for many years.
Suppose as a family-carer, I am certain (which means 'as sure as anyone ever could be') that my loved-one would not want CPR. Ethically, I must not do anything which might lead to CPR being attempted. I suspect my loved-one has just arrested: I am not a clinician, so I am not 100% certain of the arrest - whereas I am certain that any attempted CPR would be wrong.
So: I would like to be able to summon 999, to get an expert clinical opinion - to be sure it is an arrest (no treatment wanted) and not, for example, a stroke (treatment probably wanted).
It is also ethically correct, that a paramedic who I involve, should be pro-CPR until persuaded that CPR is inappropriate.
If I am aware of things such as ReSPECT, and the current guidance/protocols of 999 paramedics, could I be confident that I could call 999 with no risk that CPR would then be attempted? The answer seems to be no: so, is whatever decision I make (don't call anyone, unless it becomes clear the collapse wasn't a cardiopulmonary arrest because my loved-one isn't dying - or call 999, and if the paramedics try to attempt CPR 'forcefully object') ethically correct?
I have published my own suggestions for CPR-at-home and the interaction between family-carers and 999 paramedics, in my thread at:
The way I approached the problem, involved working from certain principles, such as it isn't reasonable 'to require impossible proofs'. And that we need to combine the clinical expertise of the paramedics, with the 'expertise in the patient as an individual' which the relatives possess. And, of course, that if CPR is involved, decision-making has to be almost instantaneous. And that an over-emphasis on written records, is problematic for several reasons - not the least of which, if CPR is involved, are the issues of verbal refusals of CPR and the legal status of 'DNACPR documents:
I would also like clinicians and family-carers, to be working with each other, not involved in some sort of 'conflict with' each other. Although if respecting the instructions of a dying loved-one would place me in conflict with clinicians, then so be it: I took my instructions from my parents when they were dying, I did not take my instructions from the clinicians who were involved (I know - as I frequently write about the MCA - that 'instructions' is a simplification: but 'it gets the point across').
I don't know, if medical ethics adds anything useful to an analysis of the problem I posed above - it seems entirely possible, that medical ethics is for practical purposes an equivalent approach to the method I use, but I am not certain. The person who suggested medical ethics is relevant, did not manage to 'resolve' the problem I posed (above) by applying medical ethics: the use of medical ethics seemed to be to identity the same complications which I identify using perspective, etc.