It follows that no such duty [exists] in the case of Anthony Bland, whose condition is in reality no more than a living death, and for whom such treatment or care would, in medical terms, be futile.51. The process results in an agreed care plan recorded on a ReSPECT form, of which recommendations on the administration of CPR are one element. This requires providers to ensure standards of documentation and record keeping and sharing of information around the system.17. It is crucial not to lose sight of this imperative and not to turn exclusively to appropriate others where someone lacks capacity, instead of attempting to involve them in the discussions. However, from a legal perspective, the only situation in which an advance decision not to administer CPR is binding is where someone refuses to consent to CPR in an advance directive.36 To administer CPR in such a case would amount to a battery.37 Here, it becomes important to understand the differences between DNACPR decisions and advance CPR refusals. As this would include an assessment of the overall quality of life to which the person would be restored, the Guidance acknowledges that the decision thus goes beyond merely clinical considerations and should therefore be made jointly with the person, at least if she has capacity.63, The MCA Code of Practice distinguishes further between cases where CPR is overly burdensome and where there is a lack of prospect of recovery.64 Case law often discusses these concepts together. (2015) have documented, concerns guidance for reviewing DNACPR recommendations. However, it was also shown that it will only be a very small number of cases in which a lack of success can be predicted with certainty, rather than based on a calculation of probabilities. British Medical Association, Resuscitation Council (UK) and Royal College of Nursing (n 1) 15. To make the most of this opportunity, attention should be paid to the need for tailored guidance and training for social work and capacity professionals, who have important roles to play in DNACPR practice. In particular, it was reported that DNACPR forms were introduced into residents records in a blanket fashion, either for all residents of particular care homes, or for all residents with specific characteristics, such as being of a certain age or suffering from cognitive impairment (Lintern, 2020; Thomas, 2020). We also sought geographic representation across regions of England and Wales. The aim of the present research was to investigate DNACPR practices within care homes during the pandemic; to better understand the role that capacity professionals might play in ensuring the lawful use of DNACPR recommendations in this setting and to consider how these professionals can best be supported in that role. In the 1960s, it became possible to apply cardiopulmonary resuscitation (CPR) when a person stops breathing or her heart stops beating. A lower level of consultation is required in cases where there is no reasonable prospect of success; more substantial consultation is expected where further elements implicating quality of life are a relevant consideration. The CQC found that 28 per cent of DNACPR recommendations were applied whilst the patient was living in a care home or in supported living (2021, Appendix B, fig. A participant information sheet was provided to all participants prior to survey and focus group participation; informed consent was obtained via the Qualtrics platform (for the survey) or email (for the focus groups) prior to data collection. Aintree University Hospitals NHS Foundation Trust v James [2013] EWCA Civ 65 [38] (Ward LJ). Certainly, one important element of a response must be to ensure that new training includes clear guidance about who should be involved in the DNACPR decision-making process, and the circumstances under which it must involve more than a narrowly clinical determination. The red form makes no reference to benefits and quality of life, but it provides as one of three possible grounds for a DNACPR decision that the patients condition indicates that CPR would have an uncertain outcome and that, after discussion, it was agreed that CPR would not be appropriate. Resuscitation Council UK, ReSPECT (n 23). As discussed, social workers have a key role to play in ensuring that the human rights of care home residents are upheld, yet, many of the professionals in our study expressed the view that the DNACPR decision-making process was out of their hands, controlled largely by clinical professionals in hospitals or GP practices. When asked to specify which medical decisions had been influenced by DNACPR recommendations, twenty-two respondents reported that a decision had been made not to transfer any residents with a DNACPR recommendation to hospital. British Medical Association, Resuscitation Council (UK) and Royal College of Nursing (n 1) 1213. The courts did not set different standards for consultation depending on the reasons for which a DNACPR decision is made. It should therefore be clarified in the Guidance on CPR that a DNACPR decision can only be regarded as purely clinical in exceptional cases where success of CPR can be excluded with certainty. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Where a person is dying from an irreversible condition, CPR may be futile, or the benefits minimal and administering it may preclude a peaceful and dignified death (General Medical Council [GMC], undated, para 128). To call them orders or instructions is misleading and risks fostering misunderstanding of their legal status. Only decisions to provide treatment require a defence against a potential battery actioneither in the form of consent, where the individual concerned has capacity, 27 or in the form of the best interests tests, where this is not the case (section 5 of the Mental Capacity Act (MCA)). Using a sequential explanatory mixed-method design, we conducted an online survey and two follow-on focus groups in the Spring of 2021 (i.e. Winspear v City Hospitals Sunderland (n 4) [46] (Blake J). When it is considered to be useful that a DNACPR decision is put in place side by side with an advance refusal, for example to record clinical reasons for such a recommendation or discussions between health professionals and patients that result in a joint view, the DNACPR form should record the existence of the advance refusal and its scope of application and that the two distinct records should be kept together. Treatment decisions always need to be personalised and take into account all the circumstances of the individual case. The second prong of futility as defined in Aintree, the lack of any benefit to the person, leaves room for including the person concerned in the decision-making process, given Lady Hales emphasis on benefits including other than medical benefits.61 This broader definition of futility therefore does not give rise to a situation where only clinical considerations guide the treatment decision. It also follows that (provided of course that they have acted reasonably and without negligence) the clinical team will not be in breach of any duty towards the patient if they withhold or withdraw it.28, While neither the consent requirement nor the best interests test of the MCA, therefore, apply to DNACPR decisions, they do apply to the decision to administer CPR. Four respondents reported that they had witnessed the denial or withdrawal of medication on the basis that a resident had a DNACPR recommendation in place. Conflict of interest statement. The person concerned has a right to be consulted and the clinical decision needs to be made in the light of the likely outcome, the patients ascertainable wishes, and his or her human rights.43 Some academics go as far as to suggest that the wishes of the person who wants to be resuscitated irrespective of the prognosis should be respected,44 which might seem to require a health professional to administer CPR against their clinical judgement if the patient so wishes. Regina (Tracey) v Cambridge University Hospitals (n 3) [65] (Lord Dyson MR). A treatment may bring some benefit to the patient even though it has no effect upon the underlying disease or disability.56. (Social Worker/BIA). Following two landmark legal cases, Tracey in 2014 and Winspear in 2015, there is a clear duty in English and Welsh law to carry out a consultation prior to recording a DNACPR recommendation. The question in Bland was whether continuing life-sustaining artificial nutrition and hydration were indicated in the best interests of Anthony Bland, who was in a persistent vegetative state (PVS). We refer to DNACPR decisions, but it is important to be clear about what decision is being referred to. They should also include a brief explanation as to why there is no chance of success. One participant stated: weve spoken at length in our team about at least a couple of care homes that I can think of in our area, where at the beginning of the pandemic GPs have gone into the homes and signed off on DNACPR orders for all of the residents. The ReSPECT form, produced by the National Resuscitation Council, serves a broader purpose, covering an array of issues pertaining to ceilings of treatment and end-of-life planning in addition to recommendations about CPR. Montgomery v Lanarkshire Health Board [2015] UKSC 11 [88] (Lord Kerr and Lord Reed). That in the end, clinical opinion seems to prevail in case of disagreement contradicts the Guidance on CPRs position that the persons decision should be followed even if there is only a small chance of success. One focus group participant described the process in these stark terms: there was no consultation with family, no consultations with the person, and, in some instances, not even a consultation with the care home staff. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Focus group participants affirmed that DNACPR forms have influenced medical decisions beyond CPR. the witness signs it, or acknowledges his signature, in P's presence. C Foster and T Hope, What Sort of DNAR Order Is That (2012) 105 J R Soc Med 279. See:
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