Transcript The Use of DNAR Orders

The Use of DNAR
Orders
Dr. Andrea Mulligan BL
LL.B, LL.M(Harv.)
S
The Use of DNAR Orders
S I. CPR in Clinical Context and DNAR Notices
S II. Irish Law and Guidance on DNAR Notices
S III. UK Law and Guidance on DNAR Notices
S IV. Tracey v Cambridge University Hospital
I. CPR in Clinical Context and DNAR
Notices
S Cardio Pulmonary Resuscitation:
S Chest compressions
S Electric shocks
S Injected medications
S Mouth-to-mouth breathing or inflation of the lungs
S Success rates – Real v. Perceived
S DNAR is a clinical decision
I. CPR in Clinical Context and DNAR
Notices
S Distinguishing DNAR’s from ADR’s
S Futile Treatment
S Terminological discussions
S DNAR – Do Not Attempt Resuscitation
S DNR – Do Not Resuscitate
S AND – Allow Natural Death
II. Irish Law and Guidance on DNAR Notices
S Constitutional background
S The right to refuse treatment
S The right to die a natural death
S The right to autonomy/self-determination
In Re SR [2012] 1 IR 305
S Boy, 1 year and 10 months old, involved in drowning
accident.
S Hospital seeks permission to make DNACPR decision.
S Kearns P
S Best interests of the child.
S Intubation and ventilation not in best interests of SR.
In Re SR [2012] 1 IR 305
S Kearns P on clinical judgment:
S One final point should be mentioned and that is whether it would
ever be appropriate for a court to require a medical practitioner to
adopt a course of treatment which in the bona fide clinical
judgment of the practitioner is not in the best interests of the
patient. Although it does not arise in the instant case, I cannot
conceive of any circumstance where such an order would be
suitable, as this would clash with the primary duty of the medical
practitioner to act in the best interests of their patient. The
Hippocratic Oath emphasises the duty on doctors to do no harm
to their patients, and that would be difficult to reconcile with an
order of the court requiring them to treat a patient in a manner
inconsistent with their own clinical judgment.
National Consent Policy (2013) - Part IV
S When CPR is appropriate
S Competent v Incompetent Patients
S However, the role of those close to the individual is not to make
the final decision regarding CPR, but rather to help the senior
healthcare professional to make the most appropriate decision.
Where CPR is judged inappropriate, it is good practice to inform
those close to the patient, but there is no need to seek their
‘permission’ not to perform CPR in these circumstances. [p99]
S Disagreements between doctor and patient
S Communication and discussion
National Consent Policy (2013) - Part IV
S DNAR notices and children
S 1. Parent(s)/legal guardian(s) and the healthcare team should work in
partnership when deciding about CPR, with decisions being made on
the basis of consensus.
S 2. Where appropriate, given the child’s level of knowledge,
understanding and experience, he/she should also be involved and
participate in the decision‐making partnership.
S 3. Therefore, children should be informed and listened to and their
ascertainable views and preferences should be taken into
consideration.
S 4. The final decision reached should be in the best interests of the
child.
S Documentation and Review
III. UK Law and Guidance on DNAR Notices
S Joint Statement (2014)
S British Medical Association, Resuscitation Council and
Royal College of Nursing.
S “Blanket” policies
S Statutory basis for advance directives: Mental Capacity
Act 2005
IV. Tracey v Cambridge University Hospital
S Core issue: To what extent a competent patient must be
informed that a DNAR decision has been made, even if
that knowledge will cause them great distress?
S Court of Appeal:
S “Since a DNACPR decision is one which will potentially
deprive the patient of life-saving treatment, there should be
a presumption in favour of patient involvement. There need
to be convincing reasons not to involve the patient.”
IV. Tracey v Cambridge University Hospital
S Exceptional significance of the decision
S Right to a second opinion
S Risk of distress not sufficient to justify non-disclosure,
must be actual harm
S Doctor’s right to refuse clinically inappropriate treatment
The Use of DNAR Orders
S Questions or comments?
S Questions and comments welcome:
S Andrea Mulligan
S [email protected]
S The Law Library, Four Courts, Dublin 7. DX 810 120