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The number of ‘do not resuscitate’ (DNR) notices being imposed without consultation is now a national scandal. What will the BMA do about it?

It’s time for a few doctors to be prosecuted or struck off

By William Oddie on Friday, 14 September 2012

Addenbrooke's hospital in Cambridge has faced legal action over the use of 'do not resuscitate' orders (Photo: PA)

It is, on the face of it, encouraging that there has been such widespread, and such critical, reporting of the case of a Down’s syndrome patient who is taking legal action against an NHS trust after a “do not resuscitate” (DNR) order was put on his medical file without his knowledge or the knowledge of his next of kin. It instructed staff not to perform resuscitation in the event of a cardio or respiratory arrest. It also gave his disability as the sole reason for its imposition.

The 51-year-old man (referred to as AWA) was admitted to the Queen Elizabeth the Queen Mother Hospital in Margate, Kent, on September 7 last year. Despite daily visits by his family and carer and meetings between his parents and the clinicians, it was only when the patient returned to his residential home that the DNR order was discovered.

As I say, this case has been well reported, and at least on the BBC Radio 5 Live breakfast programme (which I tend to listen to when John Humphrys is on the Today programme — Nicky Campbell is both fairer and better informed) with a horrified reaction, as though this kind of thing is so dreadful it must be, surely, a rare occurrence in this country— unlike, one might suggest as a contrast, Holland, where an official report has showed that in one year, Dutch physicians deliberately and intentionally ended the lives of 11,840 people by lethal overdoses or injections – a figure which accounts for 9.1% of the annual overall death rate of 130,000 per year. The majority of all euthanasia deaths in Holland are involuntary. Lethal overdoses or injections are very much worse than simply not resuscitating, of course: and we’re nowhere near being there in this country, yet. But a DNR notice, if involuntary, is well on the way to euthanasia. That’s why the assumption that this is a rare event would be reassuring, if true. But is it?

The answer is that the case of “AWA”, on closer examination, turns out to be not so rare as one might hope: it is, indeed, the tip of a large iceberg. Consider the case of a woman who was allowed to die last year in Addenbrooke’s hospital, Cambridge, and whose husband as a result took its management and the then Health Secretary Andrew Lansley to court, alleging an illegal and repeated use of DNR orders. Doctors twice put such orders in his wife’s medical notes, cancelling the first after she objected to it only to put in a second three days later without her consent or any discussion with her, as a result of which she was allowed to die without any medical intervention. Or what about the case of a woman who died in the Central Middlesex Hospital whose son discovered, in his own words, “that a do not resuscitate (DNR) notice had been placed in her file. None of the family knew anything about this, and we never knowingly signed anything like this on my mother’s behalf, nor would we have done.”

Such cases are in fact commonplace:

An investigation undertaken by the Care Quality Commission (CQC), an official watchdog, found in October last year, based on spot checks of 100 hospitals, that involuntary DNR notices are being routinely applied, without consultation with patients or relatives, to elderly patients.

On one ward, one third of DNR orders were issued without consultation with the patient or their family, according to the NHS’s own records. At another hospital, junior doctors freely admitted that the forms were routinely filled in by medical teams without the involvement of patients or relatives.

Action on Elder Abuse, an independent charity, carried out its own analysis of the CQC’s inspection reports (the CQC itself having been less than frank about the implications of its own findings). Its findings uncover widespread evidence that patients are being regularly left to die without any medical intervention, without families knowing that decisions to do so have been taken.

Documented cases include the following:

· Inspectors who visited Queen Elizabeth Hospital, run by University Hospitals Birmingham Foundation trust, found no evidence that any of the patients whose files were marked DNR had been informed about the decision, nor their relatives told. The hospital’s own audit showed that in one ward, 30 per cent of cases did not involve any such conversations.

· At University Hospitals Bristol Foundation trust, there was no evidence that a DNR order placed on a patient had been discussed with the person or next of kin. A junior doctor told inspectors that they did “not tend to discuss” such decisions with families.

· At Royal Shrewsbury Hospital, run by Shrewsbury and Telford Hospital trust, a patient was labelled as DNR based on old medical notes from a previous admission – despite the fact that their health had improved.

· Asked how decisions to make such orders were made, staff at Royal Devon and Exeter NHS Foundation trust gave an example of an elderly person on the ward with health problems judged to make “resuscitation less appropriate”. The doctor involved did not know if the patient or an advocate had been asked for an opinion, or told that the notice had been imposed.

· At Conquest Hospital, run by East Sussex Healthcare trust, incomplete DNR forms were placed on patients’ files – without their involvement, or the two doctors’ signatures required to validate them. They were then being acted on as though complete, and patients had been left to die as a result.

The simple fact is that far from being rare or unusual, as Nicky Campbell — who was rightly shocked yesterday morning by the case of “AWA” — seems to have assumed, the widespread abuse of DNR notices has assumed the proportions of a national scandal. While actual euthanasia is still illegal and likely to be prosecuted (unlike in Holland, where there is an agreement that it will not be) this is the nearest the medical profession can get to euthanasia here without too much risk of prosecution.

The fact is, however, that involuntary DNR notices are illegal. AWA is taking legal action: but this ought to be a case for the Crown Prosecution Service. I know our doctors are wonderful and that we should all be grateful to them and that we are all delighted they are so well paid now. But some of them do have a tendency towards a certain professional arrogance. A prosecution or two wouldn’t do the profession any harm. Failing that, why doesn’t the BMA do what it’s supposed to be there for? What about one or two of the worst offenders being struck off? Pour décourager les autres? That might just do it.

http://www.facebook.com/profile.php?id=1341610986 Steven Hepburn

The thrust of this argument is of course sound. It is worth pointing out, however, that CPR, physical attempts to resuscitate a person during a cardiac or respiratory arrest, has a success rate of something like 5-10%. The rate drops even lower in the frail elderly or people with long standing and/or multiple medical conditions. Furthermore a successful attempt at resuscitation on an frail elderly person is likely to result in serious damage, including multiple fractures, to the sternum and rib cage as well as extensive soft tissue and organ damage meaning that such a person might continue to live for only a short while longer but in severe pain and with massive loss of function. This is not to take into account the brain damage an already vulnerable person might suffer during the hypoxia caused by such a cardio-pulmonary event.

What this means is that survival rates would probably change hardly at all if DNAR orders were applied differently. The real cause for concern is the underlying attitude which brings about such orders without clear reference to the persons in question and their loved ones. This can vary enormously from consultant to consultant and cannot really be legislated against. It reflects the loss of value that society increasingly places on the intrinsic worth of the human person and is best tackled, essentially, be a re-evangelisation of society with the Good News about Jesus Christ and His Church.

For the record the GMC guidelines can be found here http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_when_CPR_will_not_be_successful.asp

”
134. If a patient is at foreseeable risk of cardiac or respiratory arrest and you judge that CPR should not be attempted, because it will not be successful in restarting the patient’s heart and breathing and restoring circulation, you must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made. You should not make assumptions about a patient’s wishes, but should explore in a sensitive way how willing they might be to know about a DNACPR decision. While some patients may want to be told, others may find discussion about interventions that would not be clinically appropriate burdensome and of little or no value. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.135. If you conclude that the patient does not wish to know about or discuss a DNACPR decision, you should seek their agreement to share with those close to them, with carers and with others, the information they may need to know in order to support the patient’s treatment and care.136. If a patient lacks capacity, you should inform any legal proxy and others close to the patient about the DNACPR decision and the reasons for it.”
Clearly these are being breached frequently by practitioners and this needs to be stopped as soon as possible.
Raymond Smith, M.D.

Not all CPR procedures ase caused by primary cardiac pathology.As a physician I participated in many CPR procedures where, yes , the heart (or breathing) had stopped but the cause was initially in multiple other sources. For instance drug overdosing from whatever source…”drowning”…electrical event of many kinds…sleep apnea…the ;list goes on.being elderly, disabled, etc. is not a justifiable reason for DNR especially without patient , family or guardian consultation. Ray Smith, M.D.
Dr Martin Brown MB BS

“This is the nearest the medical profession can get to euthanasia here without too much risk of prosecution”

Do not rescucitate (DNR) is NOTHING WHATSOEVER about euthanasia, which the vast majority of doctors are opposed.

Resusuitation is a treatment that can buy time in certain, specific circumstances (e.g. heart attack). The heart stops what ever the caue of death is of course: doing resucutation will not cure your lung cancer.

DNR is almost always about allowing a dignified end for those who are clearly already dying. Remember the dignified death of Jean Paul II. Would a team of doctors stripping him naked and attaching electordes to put 100s of volts into his heart after his heart stopped have helped? This is what DNR is for: to allow the dying to depart in peace.
paulpriest

Dr Oddie: I’m afraid the situations a little more awkward:

Catholic ‘ethical experts’ and alleged ‘pro-life’ activists would prefer it if you weren’t so ‘unconscionably reckless’ [their words] as to suggest there is any form of Euthanasia occurring in our hospitals via DNRs or the LCP or the Mental Capacity Act or indiscriminate arbitrary death-warrants by self-regulating hospital ethics committees; for in doing so one ‘jeopardises’ the palliative care movement and risks pro-Euthanasia activists utilising such information to argue ‘slow painful, passive euthanasia is already normative NHS practice – therefore we should legislate against such barbarity with direct active euthanasia via assisted suicide’…

Their argument: Hence any Catholic opponents to e.g. the LCP are repeatedly told to shut up and stop endangering lives…

Another manifestation of the Caiaphas Corollary: Keep quiet about the thousands being unofficially euthanised lest you risk hundreds of thousands being officially euthanised by new legislation.
Mundysfarm

Never mind the arguments belo.. DNR without consent is illegal… and for good reason!
Johanne

The issue here isn’t the efficacy or clinical outcome of CPR.

The issue is simply that attaching a DNR notice to a patient’s files without consent from either the patient, or in some cases their next of kin or those who have power of attorney for them, is not just unethical, but illegal.

I’m quite surprised that this actually goes on, not because most clinicians hold themselves to a high standard of practice, but because most professionals in many spheres of work are usually fastidious in covering their own backs from likely prosecution and civil law suits arising out of such actions.

In this instance I don’t favour prosecutions as a first principle, rather perhaps a publicity campaign from the BMA or GMC reminding our medical carers exactly what their duties and obligations really are…..
http://profile.yahoo.com/PWZKI7JBARE4DDT3NQ22RWMOJE Benedict Carter

This is an unbelievable scandal.

Just one question from me: are these doctors and medical teams doing this on their own cognizance or are they acting in response to a directive: and if so, is this directive from their local health Authority or from Government?
Rizzo the Bear

Reading this has made my blood turn ice cold!

Are chronically ill and disabled people safe, now? I would not put it past the Government that they instruct medics to do this to save the NHS money.

Insane? I wish it was but the more I think about it….

Should we now get dog tags engraved with ‘PLEASE DO ALL YOU CAN IN YOUR MEDICAL TRAINING TO SAVE MY LIFE! THANK YOU.’ or have it tattooed on our chests?

Yes, it may be a couple of crazy-sounding suggestions but what else can we do to get our message across?
Oconnord

Not so crazy, although it tends to happen the other way around…..

A British grandmother wanting to make sure that her living will was followed has had the words “Do Not Resuscitate” tattoed over her heart in large blue capital letters.And in case Joy Tomkins, of Norfolk, England, collapsed forward and medics only had a chance to look at her back, Tomkins had an additional tattoo inked on her upper right shoulder reading “P.T.O.”–for Please Turn Over–with an arrow below it pointing toward her front side.
Resuscitation

DNR orders are nothing to do with euthanasia. This misinformed article will do a great deal of harm to patients. Dying is a natural process, people who are dying should be allowed to do so with dignity. The survival rates following in-hospital resuscitation is between 5-17%! Resuscitation is a medical treatment that only works when a patient has an underlying treatable reversible cause. This is why most doctors would not choose to be resuscitated themselves. I agree that communication should take place where possible but resuscitation is and should be a medical decision. As a result of articles like this I can see me spending more time breaking the ribs of frail, elderly dying patients as doctor decide no decision is perhaps the less litigatious course of action. I for one can tell you that it is soul destroying, doctors have an over-arching ethos of “do no harm” a DNR order does not mean that we do not care for our patients, feed, medicate, provide pain relief etc. it refers specifically refers to the act of compressions / ventilations. If it is unlikely to work then we are obligated to prevent patients from being subjected to cruel or degrading treatment.
W Oddie

It is illegal to impose a DNR notice without consultation. It is not for you to decide unilaterally.
Mr75

It is perfectly legal. As a student Dr who has passed all his finals and had numerous teaching sessions on the matter I can assure you that a patient not being informed of a DNAR (as we have in the UK, DNR is american – your clearly well versed in this topic) is not illegal. It is the Dr decision to medically decide of CPR would be clinically effective not the patients, their views weigh VERY heavily in the matter but the final say rests with the Dr.

Please only post correct and accurate information on this page.
Mr75

Respectfully the UK has different laws and standards to that of the USA & consultation does not always need to take place with a patient. You have taken part in may CPR procedures in which the primary pathology is not within the heart – so you appreciate the way CPR is useless for many patients then. Also please don’t take a moral high ground, that M.D suggests you practice in the USA and we all know how corrupt the US health care system is, why not get paid less and treat the patients who cant afford non emergency care too?
Mr75

In this instance I don’t favour prosecutions as a first principle, rather perhaps a publicity campaign from the BMA or GMC reminding our medical carers exactly what their duties and obligations really are…..
This I presuem would be from a Roman Catholic perspective, as oppose to, oh I dont know, what patients want? You argue so strongly against euthanasia no IVF ect ect even when patients want to die or have IVF and then cite a religious belief that the patient doesn’t even have as a reason. We all know from the past few years of unreported abuse that the RC church could also do with reminding what its duties and obligations are. Don’t get me wrong I think this case of DNAR because the pt had downs syndrome is terrible (even tho he is very old and reached his life expectancy as patients with down have a lower life expectancy) but surly you should sort your own house out first before sanctimoniously reminding everyone else what they should be doing?
LoloJim

The ethical way for a doctor to do is to inform the patient or relatives that a DNR was put in patient’s medical record. What is so hard about that?
Resuscitation

Not in the uk, it is a medical decision. No person can demand treatment from a doctor. The key is communication, which should always take place if possible.
teigitur

Exactly!
Lewispbuckingham

”Also please do not take the moral high ground” cf your response to Raymond Smith M.D. re his being part of a corrupt system and the ad hominem implication that he consents to that, and accepts a high fee to avoid his responsibility to those who cannot afford care.
Johanne

You probably need to refresh your mind as per the provisions in the Mental Capacity Act 2005, this being the relevant legislation here as, by definition, a DNAR order will only apply when, by reason of the arrest, the patient is incapacitate.

First: the basic principle is that the clinicians must act in the patient’s best interests. In ascertaining “best interests” they must have regard to the list of criteria in s 4. Section 4(6) provides:“(6) He [the relevant clinician] must consider, so far as is reasonably ascertainable—(a) the person’s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity),(b) the beliefs and values that would be likely to influence his decision if he had capacity, and(c) the other factors that he would be likely to consider if he were able to do so.”Section 7 provides further that:“(7) He [the clinician] must take into account, if it is practicable and appropriate to consult them, the views of—(a) anyone named by the person as someone to be consulted on the matter in question or on matters of that kind,(b) anyone engaged in caring for the person or interested in his welfare,(c) any donee of a lasting power of attorney granted by the person, and(d) any deputy appointed for the person by the court,as to what would be in the person’s best interests and, in particular, as to the matters mentioned in subsection (6)”.Therefore, if, as in the case of this Down’s syndrome man, it appears that both he and his family wished for CPR to be administered to him in the event of a cardiac arrest, and this was communicated to his clinical team, then their decision to apply a DNAR notice to his files is a breach of both sections 6 and 7 of the Act above. And subsequently, illegal.
Mr75

“this being the relevant legislation here as, by definition, a DNAR order will only apply when, by reason of the arrest, the patient is incapacitate.” – DNARs apply when the patient is too ill for recus to be considered worth while it has NOTHING to do with their mental capacity. You really are making this up as you go along arn’t you. Please just stop talking utter utter rubbish.
Mr75

Sorry do you have any experience of being a Dr in the UK or USA, any TURE and REAL understanding of physicians attitudes and perspectives except for that of the one or two you may happen to know socially?
Mr75

And even if the MCA was relevant you need to read what you have written, taking into account peoples views does NOT mean their views will be followed, just their views sought. If what these doctors have done is so illegal then how come no legal challenge has been brought against them?! Why has the GMC not stepped in? BECAUSE ITS NOT ILLEGAL.
Lewispbuckingham

Have you?
scary goat

I don’t think anyone is actually against the idea of DNR. Steven Hepburn, above, made it very clear why DNR is a good idea, and I think we would all agree with that. I would certainly want DNR on my file…..BECAUSE I CHOOSE IT. The point of the article was not to criticize DNR, it was criticizing it being imposed without due consent from either the patient or their family. If it is really such a good idea, which I agree it is, there should be no problem in discussing it with at least the next of kin, if not the patient him/herself, for certain reasons. I agree that this is NOT the same thing as euthanasia, but medical staff imposing this decision without consultation is dangerously “big brother”. Slippery slope and all that.
Mr75

Yes.
Johanne

You don’t need to accuse me of ‘making this up’. You can check for yourself from the source from which I quote:

http://www.halsburyslawexchange.co.uk/dnar-orders-can-be-medico-legally-lethal/

and

http://www.halsburyslawexchange.co.uk/do-not-resuscitate-orders-a-downs-syndrome-patient-sues-the-nhs/

If you have access to the Journal of the Royal Society of Medicine you can also read the following online:

http://jrsm.rsmjournals.com/content/105/7/279.full?sid=0ed9eb7b-e2d3-4093-9d9e-a7a2de59cbf8
Johanne

Legal proceedings are being taken against the clinicians in this case, and Dr Oddie also draws our attention to “the case of a woman who was allowed to die last year in Addenbrooke’s hospital, Cambridge, and whose husband as a result took its management and the then Health Secretary Andrew Lansley to court, alleging an illegal and repeated use of DNR orders.”
elizabeth gallear

my husband went in to hospital with a bad chest a doctor put a dnr order on him the day he was admitted to hospital then on the ward a week later a nurse seen it and decided not to treat him anymore me nor any of my family knew anything about this dnr order untill it was to late we had to just sit there and watch my husband die where his lungs filled up cos they would not treat him anymore i will always say till the day i die he was murdered by the hospital
Mr75

Legal proceedings for a illegal DNAR are NOT being taken against these clinicians by the crown prosecution service for illegal imposition a DNAR / negligence / attempted murder ect ect, the patients family are taking civil proceedings against the hospital. There is a substantial difference. The proceedings against Andrews Lansley & management resulted in no action and no guilty parties were found as far as I am aware.
Rosalyn walsh

My elderly mother was repeatedly placed on DNR against her wishes and mine in November/December 2012 at St Peters Hospital, Chertsey. I was outspoken and vociferous in my complaints about these DNRs and even went to a Solicitor to have a living will drawn up and signed by my mother. Still the DNRs kept appearing. Eventually I just removed it from Mums file myself along with a page of her medical notes blatantly lying and claiming I had agreed to it! I am intending to take futher action about this and am interested in joining any protest groups which might exist.
uk social worker

Mr75, you need to read your legislation. And also control your arrogance.
uk social worker

Blimey, now you are taking on one doctor for what we perceive in this country to be the failings of the American health care system because we have the priveledge of a post war NHS structure? Which in itself is heading towards privitisation? I hope you are never my doctor, with such arrogance to make illegal decisions on my life and values. I think you need to readdress your understanding of global policies and sociological issues.

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