Recently a patient with terminal pancreatic cancer presented acutely with bowel obstruction and was admitted to hospital under our team. We discussed DNACPR with the patient, and he was in agreement that this would be appropriate to have in place. The following day, however, his wife was very unhappy this had not been discussed with her, and she asked to have the DNACPR order removed. To what extent are we as clinicians obliged to discuss a DNACPR decision with relatives, having already discussed this with the patient?
Dr Aliya Nazli, Foundation Year 1
Medical Protection advice
Medicolegal adviser Dr Marika Davies shares her advice
Discussions about Do not attempt cardiopulmonary resuscitation (DNACPR) orders are complex and sensitive and should be undertaken by an experienced member of the healthcare team. Establishing management plans in advance and, where appropriate, making and recording DNACPR decisions, can help to ensure a patient’s wishes and preferences about treatment are taken into account.
Decisions about whether CPR should be attempted are based on the circumstances and wishes of the individual patient. In this case the clinical team and the patient agreed that a DNACPR order should be put in place. This may have been because they thought CPR would not be successful, or because they thought the potential burdens and risks outweighed the benefits of prolonging life.
When a patient has capacity their wishes should be sensitively explored, and it is good practice to ask the patient if they would like those close to them to be present for support during the discussion. If the patient does not want others involved in these discussions then this should be respected. If a patient does not wish to know about or discuss a DNACPR decision, the General Medical Council (GMC) says you should seek their agreement to share information with those close to them so they can support the patient’s treatment and care.1
"Clinicians should ensure that those close to the patient, who have no legal authority, understand that their role is to help inform the decision-making process, rather than being the final decision-makers".
If a patient lacks capacity to make a decision about future CPR, and it is judged that CPR will not be successful, you should inform any legal proxy and others close to the patient about the DNACPR decision and the reasons for it. If CPR may be successful you should consult any legal proxy who has authority to make decisions for the patient. If there is no legal proxy with relevant authority you should consider any previously expressed wishes and discuss the issue with those close to the patient and with the healthcare team. Clinicians should ensure that those close to the patient, who have no legal authority, understand that their role is to help inform the decision-making process, rather than being the final decision-makers.2
If there are obvious difficulties or disagreements with family members of a patient who lacks capacity you should try to resolve these: a second opinion or case conference may be helpful. If you are unable to reach agreement you should seek advice from the trust legal department or your medical protection organisation. Careful documentation of any relevant discussions will prove invaluable if concerns are raised at a later date.
- GMC. Treatment and care towards the end of life: good practice in decision making. May 2010.
- Decisions relating to cardiopulmonary resuscitation. A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. October 2007.