In England and Wales, CPR can be performed in the event of a cardiac or pulmonary arrest unless a do not resuscitate order is in place. Patients with mental capacity however can choose not to be resuscitated. Patients also can delegate their decision-making to their next of kin by way of a Lasting Power of Attorney. However, if the doctor believes that treatment (including CPR) is futile, the doctor may decide to discontinue treatment in the best interests of the patient.
The most disappointing element of DNR is that the patients and their families are not required to consent to an order, which means that the doctor can issue a DNR order even if the patient and their family do not want one.
Nevertheless, there are guidelines issued by the British Medical Association and the Royal College of Nursing that state that DNR orders should only be issued after discussion with patients or their family.
When is a DNR decision made?
There are three main circumstances in which the law allows DNR decisions to be made:
- The patient may voluntarily ask not to be resuscitated. This can be requested by the patient at any time and when a DNR order is implemented all healthcare professionals must respect it and not attempt resuscitation.
- A DNR order can also be made by the doctor if he considers that resuscitation is likely to be “futile”, for example if they do not believe that CPR will work.
- When the burden of CPR outweighs the benefit to the patient, i.e. when CPR may restart the heart and breathing, but the patient is likely to be left with a poor quality of life.
The patient should be provided with detailed information about DNR. The patient may confirm that they do not wish to discuss DNR any further and leave it up to the doctors to decide. This of course has to be reflected within the patient’s medical records.
The patient is entitled to have a discussion with a doctor, who is going to make a DNR order, so they can provide their comments and ask questions and receive the doctor’s professional opinion.
The decision made by the doctor should be communicated to the patient providing the reasons why the decision was made. Sometimes the patient does not agree to the decision and out of courtesy the doctor should give the patient the option of seeking a second opinion.
In cases of disagreement
When there is a disagreement between the patient and the doctor about whether the DNR order should be made, the first step would be a discussion with a senior doctor. The patient is entitled to obtain a second opinion as to whether CPR would work. Of course, if an agreement cannot be reached, the patient should seek legal advice. However, the patient and his or her relatives should bear in mind that the court will not make an order for a doctor to provide treatment which in their professional opinion is not in the best interests of the patient.
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