Dr. Simon Hodes and Doctor Ben Eliad discuss issues related to end-of-life care, including do-not-resuscitate decisions
During the pandemic, instructions were sent to healthcare organizations to ensure advance care planning was in place for patients at risk, including do not attempt cardiopulmonary resuscitation (DNACPR) forms for those who wanted it. It was timely. Compassion in Dying saw the proportion of calls to its DNACPR information line more than double in 2020,1 most people preferring to refuse CPR if they become seriously ill.
However, a number of DNACPR decisions may have been made in haste, without the normal levels of discussion – and in some cases as a blanket decision based on age alone, or living with a learning or physical disability. . The CQC report Protect, Respect and Connect2 found evidence to suggest that more than 500 DNACPR decisions made since March 2020 may not have been properly discussed with the person or their family. Compassion in Dying also identified many poor communication and decision-making issues in DNACPRs that predated and were exacerbated by the pandemic.
This can provide valuable lessons for general practitioners. Making a DNACPR decision without consulting the patient or their family is not only illegal, but harms the doctor-patient relationship and the broader public trust in the medical establishment. Ideally, we should discuss advance care planning options well in advance of any need, so that patients’ wishes can be clearly documented while they are in relatively good health and at full mental capacity. When done well, these discussions are comforting for patients and families, and are essential for end-of-life planning.
Key learning points
- To have capacity, a person must be able to understand, remember, weigh and communicate their decision
- A DNACPR decision is made by clinicians and does not require patient consent. However, clinicians are normally required to discuss and explain the decision to the patient or their family or lawyer.
- Be aware of broader advance care planning tools, including advance rulings and health AALs, as well as DNACPR and ReSPECT, and that patients may also want to plan for situations after death, including funeral plans and financial problems
- Conduct sensitive conversations with patients and their loved ones in safe and protected environments, and translate them into clear action plans
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