Wednesday, 26 March 2008


I thought I'd have a return to ethics today. However, I'm avoiding the hybrid embryo debate in favour of something a little more directly clinical. A family has complained to the GMC because they said an order not to resuscitate was on their mother's notes, and they had not been consulted on this.

Initial (knee jerk) reaction is that this is a case of poor communication. The facts are scant, so it's impossible to say in this case.

Are there circumstances under which a DNR could be put on notes, and the family not informed? Suppose a patient asked not to be resuscitated, but wanted that decision to be kept from their family, to avoid distressing them or to avoid argument. Can a DNR be a private matter between patient and their care team? Does a member of the care team have a right to tell the family what the patient wishes to be kept from them? This seems to be the flip side of the question of what the patient has a right to know. If my relative is terminally ill, but I believe they can't cope with knowing that, do I have any right to ask the care team not to tell my relative how ill they are?

Part of the issue is whether a person refusing resuscitation is competent to make that decision. A person may be deemed competent to make some decisions about their care, but not others. A person has the right to make a decision that a healthcare professional might feel to be against their own, personal code of morals and beliefs.
A DNR decision can be made before we are even unwell, as part of a "living will" or advanced directive.

All trusts should have a policy on DNR orders. The BMA, RCN and Resuscitation Council (UK) issued a joint statement last year on "Decisions relating to Cardiopulmonary Resuscitation". Many of the main points of this document involve communication, capacity and the right of the patient to make decisions about their care. It specifically says (on p18) that "refusal by a patient with capacity to allow information to be disclosed to family or friends must be respected." In other words, a DNR, agreed by a competent patient and a care team, can legitimately be on a patient's notes, without the family and friends being consulted or informed.

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