Almost every hospital has introduced Do Not Attempt Resuscitation policies, procedures and forms, and clinical staff have become better at discussing death and resuscitation with patients. For those involved in hospice care and palliative care teams, however, the management of death goes well beyond the issue of whether to resuscitate or not. An alternative, more positive way of thinking about death in people with advanced disease is labelled Allow a Natural Death’ (AND).[19] Allowing a natural death simply means not interfering with the dying process whilst providing care that will keep the patient as comfortable as possible. Allow a Natural Death orders are intended for terminally ill patients who are being cared for in hospices, care homes or at home, but there is no reason why these should not be applied to patients in acute hospital wards as well. The NHS Gold Standards Framework enables generic care providers, such as primary care, care homes, and palliative care settings to deliver a gold standard of care for all people nearing the end of their life, [20] and there is an ‘Allow a Natural Death’ form on their website.[21] The Avon, Somerset and Wiltshire Cancer Services also have an ‘Allow a Natural Death’ form on their website.[22] Dignity in Dying is an organisation dedicated to ensuring choice about where to die, who is present during death and treatment options, and provides access to expert information, good quality end-of-life care, support for loved ones and carers, together with advice on symptoms, and pain relief [23] A decision to ‘Allow a Natural Death’ should be communicated in writing by professional clinicians to the local Ambulance or Emergency Services dispatch control centre to avoid resuscitation if that person should unexpectedly collapse. However, at present there are no national arrangements or systematic ways of communicating DNAR orders across all potential healthcare settings. We already use national NHS consent and DNAR forms in our hospitals, so it should not be difficult to extend this and register such forms with the emergency services; Advanced Directives or “Living Wills” could also be included. Of course, a DNAR form or Advanced Directive would need to satisfy the various legal requirements of a written document: it must be signed by the patient and a witness, the patient must have demonstrated adequate mental capacity to make the decision at the time, and the order or directive would have to be applicable to their current illness or condition. Safeguards against fraudulent entries and the influence of overzealous relatives would be necessary - for example, the witness and co-signatory might be a person who knows the patient in a professional capacity, such as their GP, solicitor, priest or minister. Arrangements could be made for patients to reregister or renew these documents annually. Obviously, legal and confidentiality safeguards would also be required with regard to the sharing of the information contained in these forms across different emergency services and healthcare organisations. Such forms could be stored electronically and shared online so that when an emergency call is received about a patient with a DNAR order or Advanced Directive, this would immediately be flagged up and the contents notified to the emergency controller.
Clinical staff are not obliged to offer resuscitation to every patient; doctors do not have to offer or provide treatments that are futile. If a patient has an advanced terminal illness with no realistic chance of improvement, doctors do not have to undertake resuscitation in the event of a cardio-respiratory arrest; it would be considered unethical. However, sometimes a patient or their family cannot accept that unavoidable death may be close, and insist that ‘everything must be done’. Where there is a persistent discrepancy between the views of the patient or their family and the clinical staff, it is good medical practice to seek additional opinions and advice from experienced doctors not directly involved in the case.
The General Medical Council in The United Kingdom has published guidance on ‘Treatment and care towards the end of life: Good practice in decision making’.[24] This guidance is based on long-established ethical principles, which include a doctor’s obligation to show respect for human life; to protect the health of patients; to treat patients with respect; and to make the care of their patient their first concern. Patients who are approaching the end of their life need high-quality treatment and care to help them to live as well as possible until they die, and to die with dignity. The guidance identifies a number of challenges in ensuring that patients receive such care, and provides a framework to support doctors in addressing the issues in a way that will meet the needs of individual patients. It emphasises the importance of communication between clinicians and healthcare teams when patients move between different care settings (hospital, ambulance, care home), and during any out-of-hours period. Failure to communicate relevant information can lead to inappropriate treatment being given or failure to meet the patient’s needs.
Decisions relating to resuscitation cannot be made by patients who are not mentally capable of understanding their condition, the obvious example being when the patient is unconscious. A patient must be able to understand, retain, and weigh information about themselves, and be able to communicate in some form, in order to make a rational decision about their medical care.
There are variations in different jurisdictions regarding the legal tests and requirements to determine whether a patient has the mental capacity to make such decisions, but the general medical principles are common to most circumstances. In order to demonstrate effective mental capacity, a person should be able to understand what the medical treatment is, its purpose and nature, and why it is being proposed; as well as comprehending its benefits, risks and the alternatives; they must understand, in broad terms, what will be the consequences of not receiving the proposed treatment; be able to weigh the information in the balance to arrive at a choice; retain the information for long enough to make an effective decision; and make a free choice without external pressure. Different medical treatments may require different levels of mental capacity; for example, the consent process for having a blood sample taken requires a lower degree of weighing and retaining information, compared with the consent process for major, life-threatening cardiac or abdominal surgery. If a patient lacks the mental capacity to make a decision about their care, this should be noted in their medical records, and the clinical reasons for it.
If a patient lacks adequate mental capacity, then the decision must be made for them in their best interests and urgent medical interventions can be performed, particularly in the case of emergency or life-saving treatments. In the case of serious procedures to be done without consent, it is good medical practice to consider alternative, less invasive treatments; to discuss treatment with all members of the healthcare team; to discussing treatment with the patient as far as possible; to consult with other healthcare professionals involved with the patient’s care (for example, their general practitioner); to consult relatives, partners and carers; to obtain further opinions from experienced doctors if the patient or their family do not agree with the proposed treatment; and to ensure a record is made of the discussions and any decision taken.
20
The NHS National Gold Standards Framework Centre. http://www.goldstandards framework.nhs.uk/
22
Avon, Somerset and Wiltshire Cancer Services Allow a Natural Death (do not attempt resuscitation) Order. http://www.aswcs.nhs.uk/
24
Treatment and care towards the end of life: Good practice in decision making. http://www.gmc-uk.org/End_of_life.pdf_32486688.pdf