What happens when a DNACPR decision is not in place?
A DNACPR recommendation may be made if a doctor feels that it would not be in the patient’s interest to perform CPR. But what happens if there is no DNACPR recommendation in place? The law here is complex, and there can be serious consequences for clinicians whose decisions are challenged.
Usually, before a clinician administers any form of treatment, they must gain the consent of the patient. In the case of cardiac arrest, however, it is not possible to do so because the patient is invariably unconscious. The clinician must therefore make a decision on behalf of their patient. Decisions like these, where a person cannot consent to treatment, are governed by the Mental Capacity Act 2005, and are known as ‘best-interests decisions’. Section 4 of the Act lays out the steps that a person must take in order to arrive at a best-interests decision, and section 5 says that, as long as a person takes these steps, and adheres to the principles of the MCA, they will be protected from liability for administering treatment, even without the patient’s consent.
In arriving at a best-interests decision, a clinician must take into consideration ‘as far as is reasonably ascertainable’ the wishes, feelings, beliefs and values of the patient. Where it is ‘practicable and appropriate,’ they must consult those who care for the patient, such a family members, in order to understand what these wishes, feelings, beliefs and values are likely to be. In the circumstance of a cardiac arrest, however, there is little time in which to arrive at a best-interests decision, and the above steps may not, therefore, be reasonable, practicable, or appropriate. In practice, then, the decision will usually fall largely to the clinician’s own judgment.
It has been established in case law that where there is doubt as to the wishes of the patient, there should be a presumption in favour of preserving life. This means that, if a DNACPR decision is not in place and there is a chance that CPR will be successful, clinicians are likely to perform CPR.
When, then, might clinicians withhold CPR? There are cases where it will be apparent to the clinician that CPR will not be successful, and in these cases, guidance states that CPR should be withheld. These include cases where there are signs of advanced and irreversible death, such as rigor mortis or decomposition, as well as cases where there are catastrophic injuries that cannot be survived, such as decapitation. Guidance also states that CPR should be withheld where a person is in the advanced stages of dying from a terminal illness.
In practice, however, CPR is not always withheld in these circumstances. In recent years, there have been a number of cases where nurses have faced professional sanctions or prosecution because they did not perform CPR, even in cases where they believed that it would not be successful, and it is the policy of some care homes to require that CPR is performed under all circumstances except where a DNACPR recommendation is in place. If it is believed that it may not be in the interests of a person to receive CPR should cardiac arrest occur, it is therefore important to discuss the possibility of a DNACPR recommendation before a cardiac arrest takes place. Ideally, this should happen as part of a broader discussion about end-of-life care.
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