By Catriona McMillan and Victoria Sobolewska
Patient-doctor discussions surrounding do not attempt cardio-pulmonary resuscitation (DNACPR) orders amidst the COVID-19 pandemic have caused widespread, understandable panic in the UK, set against a backdrop of proportionately higher elderly deaths, discussions surrounding resource allocation (particularly with reference to ventilators), and emerging stories of rising care home deaths. Here, we highlight how current debates surrounding DNACPRs – and advanced care planning more generally – raise important lessons for the future surrounding how we might improve when clinicians and patients have these discussions in the process of care.
There is an understandable fear amidst the public at the moment that having a DNACPR order in place means that doctors will not try to save your life. This is not the case. The GMC guidance is clear that DNACPR orders do not imply that other treatments, for example oxygen, fluids, or antibiotics will be withheld or withdrawn. Moreover, DNACPR orders are not legally binding. Where DNACPR order has been made, CPR is still advised in certain situations, for example in cases of respiratory arrest from a reversible cause. However, it is important to be clear with patients that CPR is an undignified process, used to try to restart the heart. If successful, almost all patients require admission to ITU for ventilation, and this might not always be appropriate in patients with certain underlying co-morbidities, as full recovery would be very unlikely. The BMA ethical guidance on COVID-19 notes:
The pandemic, and the restricted availability of intensive care, will influence other clinical decision making within the hospital. For example, it will be important for clinicians to review and document the appropriateness of cardiopulmonary resuscitation for all inpatients (with or without COVID-19 associated illness) where there is a possibility of acute deterioration. If patients have sufficient background illness, co-morbidity and/or frailty that they would not be admitted to intensive care (because of the necessary restrictions on admissions), it is important that cardio-pulmonary resuscitation is not commenced in the event of a collapse. Performing advanced resuscitation for a patient for whom post-resuscitation intensive care cannot be provided would potentially cause harm to the patient, consume limited resources at a time of considerable strain, and potentially put the resuscitation team at unnecessary personal risk.
Ultimately the decision to put an order in place lies with the clinician, not the patient. However, clinicians considering making a recommendation for a DNACPR order, there is a legal requirement for them to discuss the matter with the patient (see Tracey v Cambridge University Hospital NHS Foundation). Exceptions to this are where a patient does not wish to discuss it, or if the clinician believes the discussion would cause the patient psychological harm (more than ‘distress’). Where patient lacks capacity to participate in discussion, clinicians must involve those appropriately interested in their welfare, for example a family member (see Winspear v City Hospitals Sundeerland NHS Foundation Trust).
We should carefully consider the ways in which we can learn from the understandable widespread concern surrounding DNACPRs in the context of COVID-19. As Ruth May (Chief Nursing Officer) and Stephen Powis (National Medical Director) have made clear, it is important that blanket polices with reference to age, disability, or medical condition should not be adopted amidst this crisis. It is crucial that this continues to be the case.
Reflection on the effects of the above concerns raised during this pandemic enables us to be more thorough with respect to when this decision process takes place between patient and clinician. Early discussions surrounding advance care decisions also enables patients to have more detailed, clear discussions surrounding why a DNACPR order has been suggested by their clinician. In urgent situations, for example at the time of an acute presentation to hospital, patients may be unable to communicate their wishes, or rationalise information about the likely effects of CPR (although this is certainly not always the case). Having these discussions while acutely unwell can cause distress, and have a detrimental effect to patient wellbeing. Facilitating advance care discussions when patients are well enables effective, sensitive communication, and avoids impersonal – and for some, alarming – methods such as letters. Making these decisions before triage thus enables clear doctor-patient communication as to a) why the patient may, or may not want a DNACPR order, and b) why the clinician does or does not believe a DNACPR order is appropriate. Dignity is a key factor in any discussion surrounding the end of life, and having these discussions earlier in the care process allows patients to consider what dying with dignity means for them, and while the decision ultimately lies with their clinician, it can also empower the patient to, for example, decide to stay at home for their last hours or days if they so wish.
Initiatives to reflect these suggestions are already underway. The ReSPECT form is a process to develop, and keep under review, choices about clinical care in emergency. Advance processes such as these enable patients to clearly distil and reflect their priorities in writing. However, this initiative is only being used in a few places at the moment. Public concerns raised about DNACPRs during the COVID-19 pandemic gives us opportunity to reflect on how we can improve normative clinical practice surrounding advance care planning in the long-term, for example by using ReSPECT forms, or advance statements. By improving the facilitation of patient-doctor and family discussions surrounding the end of life as common practice where appropriate, we can enable many more patients to record and update their wishes (in a legally valid manner), so that they are in place before any emergency care is required.
Authors and Affiliations:
Dr Catriona McMillan, Senior Research Fellow in Medical Law and Ethics, University of Edinburgh. Twitter: katy_mcmillan.
Dr Victoria Sobolewska, Internal Medicine Trainee, NHS Lothian.