The [probably horrible] consequences for a relative of supporting a healthy loved-one's decision to forbid CPR
There was a recent Twitter discussion (see the PDF) and the problem of a healthy person's decision to forbid attempted cardiopulmonary resuscitation (CPR) cropped up. The problem is a fundamental asymmetry of knowledge, between a relative who phones 999 to find out whether a person is in arrest, and the 999 paramedic who attends. Put simply:
If the person is in cardiopulmonary arrest, the relative does not consider there is any decision to be made - 'I know CPR has been forbidden, so it should not be attempted';
The paramedic knows whether the person is in cardiopulmonary arrest - but the guidance for 999 paramedics, doesn't prevent them from attempting CPR when the relative says 'I KNOW he doesn't want CPR - he has made that very clear TO ME!'.
So, you can have the situation a healthy tweeter who personally wants to forbid attempted CPR described in some tweets:
'[I] have appointed my wife as LPA(health) and she is willing to interpose her body between mine and the paramedic.'
The PDF examines what is likely to happen AFTER 'the wife has stood between the paramedic and the person, in order to prevent the paramedic from attempting CPR' - at the moment, to put it simply, 'the wife is placed in 'an impossible situation' because of the guidance clinicians are writing for themselves'.
I would point to something the Association of Ambulance Chief Executives has said, which is of relevance here - see page 54 in my piece at:
https://www.dignityincare.org.uk/Discuss-and-debate/download/317/
The AACE told the House of Commons Health Committee:
'Without a DNACPR form or information that establishes that a person is at the end of life, resuscitation may be the course of action decided upon by the clinician that may be later seen as unethical, inappropriate and most importantly not what the patient would have wished for.'
Well - the relative who phoned 999 has no doubt about 'most importantly not what the patient would have wished for', so why would the paramedic 'decide to attempt CPR'?
I would add, that there are conceptual problems with 'DNACPR forms' in this situation - legally an Advance Decision refusing CPR should 'be the solution', but in reality the ADRT works far less well than it ought to.
Associated files and links:
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Standing between a 999 Paramedic and a person who is in cardiopulmonary arrest
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Just noticed a mistake:
Wife to Police: Because I’m her attorney with decision-making authority over CPR – and despite my telling the paramedic to not attempt CPR, it was clear the paramedic was going to attempt CPR.
My excuse - I had drafted the piece, when 'her attorney' would have made sense: then I was asked to change it and I did, but that one slipped through, so it should say:
Wife to Police: Because I’m his attorney with decision-making authority over CPR – and despite my telling the paramedic to not attempt CPR, it was clear the paramedic was going to attempt CPR.
Note to the person who asked me to change my scenario - you know who you are [and I make enough mistakes even if I don't have to do such re-editing!]. :)
There has been a recent discussion of this on Twitter. Kathryn Mannix is the doctor who wrote the much-praised book 'With the End in Mind', and Kate Masters is one of Janet Tracey's daughters: the 'Tracey' court ruling means that doctors must now usually tell patients and/or relatives if the doctors intend to put a 'clinical DNACPR' in place. 'Mike Stone' is, of course, me. I've taken out a few tweets which stray a little into a different topic - and this thread started with discussion of something slightly different, so I'm 'sticking on theme' here. I think you 'find' the 'missing' tweets anyway, if you go to the URL I'm posting for the first tweet.
https://twitter.com/MikeStone2_EoL/status/1098551924008325120
Mike Stone:
Twitter - right, okay - but many doctors do seem to believe they have a legal right to ask patients questions such as 'why are you refusing CPR - you are currently quite healthy?'. They can ask - but you don't have to tell them.
Kathryn Mannix:
Mike, doc has 'ethical duty' to ensure the decision isn't based on a misunderstanding that might entirely change the person's decision if explained. Patient has the right to make an illogical decision, of course, but we're not checking their logic, we're 'avoiding harm.'
I (Mike) then tweeted a link to my piece at
https://www.bmj.com/content/353/bmj.i2230/rr-7
which in essence asks 'whose ethics?', and then
Mike Stone:
I'm wondering Kathryn - what do YOU think the 'moral duty' is for family-carers, when 999 staff are doing something 'I know my mum would have refused!'.
Kathryn Mannix:
To lie across their beloved parent screaming 'Get away!'
But in the moment, the confusion, the sadness, who would think to do so?
I absolutely agree with you on this.
Kate Masters:
They’d be arrested.
Kathryn Mannix:
Sadly, you're probably right.
What a state of affairs...
Kate Masters:
It’s a mess and it has to be sorted. So many people with passion in this thread, talking to people about talking to people, that much passion should be swept up and put to action to sort the mess out.