RESPONSIBILITY FOR DECISION-MAKING: PATIENTS AND THEIR RELATIVES/CARERS
A competent patient can:
Make an advance refusal of CPR
- even if CPR is deemed to be very likely to be medically successful
- they do not have to give a reason for such refusal.
Accept (consent to) CPR if offered
- CPR must only be offered if it is realistically judged likely to be medically successful in achieving sustainable life for that patient in the event of a cardio-respiratory arrest.
A patient who has capacity cannot:
Demand CPR if it is clinically judged that it would not be medically successful in achieving sustainable life for that patient
- healthcare staff cannot be obliged to carry out interventions that they judge are not indicated/ may be harmful
- if agreement cannot be reached after sensitive and open discussion, a second opinion should be accessed.
Where a patient lacks capacity for involvement in advance decisions and has no legally appointed welfare attorney/welfare guardian/person appointed under an intervention order
- the responsibility for deciding if resuscitation is in the patient's best interests lies with the lead clinician with clinical responsibility for the patient
- family/carers/next of kin do not have decision-making rights or responsibilities in this circumstance. Discussion with the family has the primary aim of trying to clarify the patient's views, prior to incapacity.
Where a patient lacks capacity for involvement in advance decisions and a legally appointed welfare attorney/welfare guardian/person appointed under an intervention order has been identified
The proxy decision maker can
- make an advance refusal of CPR for the patient
- accept (consent to) CPR if offered (and realistically judged by the senior clinician to be likely to achieve sustainable life for the patient).
The proxy decision maker cannot
- demand CPR if it is clear that CPR will not be successful in achieving sustainable life for the patient
- if agreement cannot be reached after sensitive discussion, a second opinion should be accessed.
Advance decisions about CPR can be difficult and can cause considerable emotional distress but they can also be extremely reassuring and a huge relief for some patients. It is important that patients are involved as far as possible in decisions regarding their care. However, the following points are important to remember:
1. It is unnecessarily burdensome to insist on discussing treatments that are futile and will not be offered, unless there is obvious benefit for the patient in having such a discussion (such a benefit might be having a DNACPR form at home with the patient; or pre-empting a situation where a patient is likely to come across their DNACPR form without support). It is obviously still important that the patient is given ample opportunity to discuss their hopes and fears regarding their end-of-life care.
2. Family/carers of a patient who has capacity should not be involved in resuscitation discussions without that patient's consent. Consent to discuss the benefits of a DNACPR form with family/ carers may be implicit in consent from the patient to discuss all aspects of their end of life care.
3. Relatives who are not legally appointed as the patient's legal welfare guardian should never be placed in a position such that they feel they are making a DNACPR decision. Their role is to provide information about the patient's previously expressed wishes, beliefs, values and preferences or what they believe the patient would wish in this situation. If they have been legally appointed as the patient's welfare attorney/welfare guardian/person appointed under an intervention order they can consent to or refuse medical treatment on the patient's behalf.