Amit Arora is a consultant physician in care of older people and Chair of the England Council of the BGS.
A landmark ruling was recently handed down by the Court of Appeal in the case of Janet Tracey v Cambridge University Hospital NHS Foundation Trust and others. The Court ruled that Cambridge University Hospital Trust violated Mrs Tracey’s (Article 8 of the European Convention on Human Rights) Right to Respect for Private Life in failing to involve her in the process which led to making a DNAR decision. It also said that it was a duty of common law to consult.
Other Noteworthy comments were that:
- The Court rejected that a DNAR discussion had taken place as it was not documented
- The Court ruling suggested it would have been unlikely to have intervened if the lack of a DNAR discussion had been documented with a supporting claim that it would ‘cause distress which would cause harm’
- The Court rejected that the Secretary of State for Health should provide national DNAR guidance
- The Court rejected that the Trust did not have a clear DNAR policy
Without going into too many details it appears that doctors will now, more than ever, be required to consult patients and/or relatives in making DNAR decisions. This has always been GMC’s good practice guidance but the Court ruling now makes it much more important and ‘a legal requirement’ and puts the onus on Doctors much more than previously. At the time of writing this, none of the national bodies like GMC, BMA, Royal College of Physicians, British Geriatrics Society or Society for Palliative Care have done an interim guidance or statement.
The questions that this ruling might pose are:
- Do we need to train our staff better in holding these extremely sensitive discussions? Probably yes.
- Are we going to see a reluctance to complete DNARs as this is now a legal obligation to discuss with patient or relatives? Maybe or probably not!
- There is certain ambiguity in the terminology, in that the Court ruling mentions that there can be valid grounds not to discuss DNAR decisions if it is likely to cause physical or psychological harm to the patient. How will this be interpreted when making these decisions? Are the patients ready for this?
- And finally what would happen to the decisions already made and existing DNAR forms which are currently in place but there is no clear evidence of discussion of this decision with patients or families?
Currently about 500,000 people die in England each year and 58% of these die in hospitals. It is an important decision for geriatricians (and other doctors) to make. It is known that survival to hospital discharge for cardiac arrest is 10.7% but when taking into account pulseless electrical activity (PEA) and asystole separately this drops to 7%. Furthermore, patients with dementia are three times less likely to survive in hospital after cardio-pulmonary resuscitation and this success rate is almost as low as for metastatic cancer. Taking age as a factor, the survival rate is 3.9% for 80-89 years old and 1% in 90 and older.
It is clear that as geriatricians we should be more pro-active in the early stages of hospital admission to make DNAR decisions. It becomes more relevant if they meet the ‘end of life criteria’ as defined by the ‘Gold Standards Framework’ and the GMC and RCP guidance suggests we should be considering DNAR decisions for such patients.
This Court ruling puts much more emphasis on doctors discussing DNAR decisions with patients and families. What is needed is a timely, detailed and considerate discussion with patients and/or families as to what it involves and in what way it may or may not affect ongoing treatments. Better training of staff is a must to deal with such a sensitive issue.
The Court ruling, however, may also mean that some trusts may feel the need to issuing interim guidance. Increased awareness amongst public and medical professionals around this ever-sensitive topic can only make this difficult job somewhat easier.