A difficult conversation
Post date: 27/10/2017 | Time to read article: 2 minsThe information within this article was correct at the time of publishing. Last updated 14/11/2018
When it comes to Do Not Attempt Cardiopulmonary Resuscitation, Medical Protection’s Medicolegal Adviser Dr Nicky King reflects on a junior doctor’s position.
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is a highly emotive area which can cause considerable distress for patients and their families and is fraught with the potential for complaints 1. Clinicians have previously considered that if CPR was clearly going to be unsuccessful and that a discussion regarding DNACPR would distress the patient it was acceptable to place on order on a patient’s records without discussion with them or their family. The recent court case of Tracey v Cambridgeshire NHS Foundation Trust (2014)2 has established that clinicians now have a legal duty to consult with and inform patients if they want to place a DNACPR order on medical notes and there needs to be convincing reasons not to involve the patient; the fear of causing distress is not sufficient to avoid the discussion.
Junior doctors may find themselves in a position of needing to consider DNACPR orders and to have these difficult conversations. Problems generally arise for two reasons – poor communication and misconceptions regarding what CPR actually entails; the likely success and what having a DNACPR order in place means in reality.
CPR should be discussed in the context of the patient’s overall care, not in isolation. Communication involves listening as well as providing information and a good starting point can be to ask the patient what they have understood about their current situation and future care plans. This not only helps to start a difficult conversation but also enables you to hear the ‘language’ the patient uses and clarify any misconceptions. Continuing the discussion using the same terminology as the patient shows empathy and improves their satisfaction with the consultation. Patients fear that a DNACPR order means all care is withdrawn and it is important to have been clear regarding what measures are in place for actively managing symptoms and reversible conditions.
The second area which causes problems seems to arise from the public misconception regarding the success of CPR. There is a lack of understanding that the heart will stop as part of the process of dying and attempting to restart the heart with CPR would provide no benefit in such situations. The success of CPR is also over estimated, probably based on TV soaps and dramas where considerably more patients make a full successful recovery than in reality. The GMC End of Life Care guidance points out the low success rate of CPR and the risks involved, and that inappropriately attempting CPR may result in the patient dying in an undignified and traumatic manner 3.
A further recent legal case4 has confirmed that the duty to consult applies in cases both of capacity and absence of capacity. For patients who lack capacity a family member or person representing the patient’s interests5 should be consulted before a DNACPR decision is put in place. Families often need the reassurance that the clinicians are not ‘giving up’ on their loved one.
The BMA have recently launched a project to examine both the public and medical professionals’ attitudes on aspects of end of life care6 .The outcome of the project will hopefully improve the way these difficult situations are managed and discussed, resulting in improved experiences of end of life care.
R (Tracey) v Cambridge University Hospitals NHS Foundation Trust & Ors [2014] EWCA Civ 822
gmcuk.org/guidance/ethical_guidance/end_of_life_CPR_cardiopulmonary_resuscitation.asp
Winspear v City Hospital NHS FT (Nov 2015) [2015] EWHC 3250 (QB), [2015] WLR(D) 468
Mental Capacity Act 2005 s4(7)
bma.org.uk/endoflifecare
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is a highly emotive area which can cause considerable distress for patients and their families and is fraught with the potential for complaints 1. Clinicians have previously considered that if CPR was clearly going to be unsuccessful and that a discussion regarding DNACPR would distress the patient it was acceptable to place on order on a patient’s records without discussion with them or their family. The recent court case of Tracey v Cambridgeshire NHS Foundation Trust (2014)2 has established that clinicians now have a legal duty to consult with and inform patients if they want to place a DNACPR order on medical notes and there needs to be convincing reasons not to involve the patient; the fear of causing distress is not sufficient to avoid the discussion.
Junior doctors may find themselves in a position of needing to consider DNACPR orders and to have these difficult conversations. Problems generally arise for two reasons – poor communication and misconceptions regarding what CPR actually entails; the likely success and what having a DNACPR order in place means in reality.
CPR should be discussed in the context of the patient’s overall care, not in isolation. Communication involves listening as well as providing information and a good starting point can be to ask the patient what they have understood about their current situation and future care plans. This not only helps to start a difficult conversation but also enables you to hear the ‘language’ the patient uses and clarify any misconceptions. Continuing the discussion using the same terminology as the patient shows empathy and improves their satisfaction with the consultation. Patients fear that a DNACPR order means all care is withdrawn and it is important to have been clear regarding what measures are in place for actively managing symptoms and reversible conditions.
The second area which causes problems seems to arise from the public misconception regarding the success of CPR. There is a lack of understanding that the heart will stop as part of the process of dying and attempting to restart the heart with CPR would provide no benefit in such situations. The success of CPR is also over estimated, probably based on TV soaps and dramas where considerably more patients make a full successful recovery than in reality. The GMC End of Life Care guidance points out the low success rate of CPR and the risks involved, and that inappropriately attempting CPR may result in the patient dying in an undignified and traumatic manner 3.
A further recent legal case4 has confirmed that the duty to consult applies in cases both of capacity and absence of capacity. For patients who lack capacity a family member or person representing the patient’s interests5 should be consulted before a DNACPR decision is put in place. Families often need the reassurance that the clinicians are not ‘giving up’ on their loved one.
The BMA have recently launched a project to examine both the public and medical professionals’ attitudes on aspects of end of life care6 .The outcome of the project will hopefully improve the way these difficult situations are managed and discussed, resulting in improved experiences of end of life care.
References
resus.org.uk/statements/emergency-care-and-cprdecision-making/R (Tracey) v Cambridge University Hospitals NHS Foundation Trust & Ors [2014] EWCA Civ 822
gmcuk.org/guidance/ethical_guidance/end_of_life_CPR_cardiopulmonary_resuscitation.asp
Winspear v City Hospital NHS FT (Nov 2015) [2015] EWHC 3250 (QB), [2015] WLR(D) 468
Mental Capacity Act 2005 s4(7)
bma.org.uk/endoflifecare
