EARLIER this year I wrote in TCW about my 88-year-old aunt being given a Do Not Resuscitate order (DNR) on the day that she was admitted to hospital in Wales in April 2020. This was placed on her medical record.
She had fallen at home, and the First Responder who came to assess her noted that she was unable to support herself when using her walking frame.
Having waved her off alone in an ambulance, I vividly recall my telephone conversation several hours later with the doctor who had examined her. He said that her kidney function was below par and that since she was ‘frail’, he had discussed a Do Not Resuscitateorder with her and that she had agreed to this. It was only after she was discharged seven or eight weeks later that it was appropriate to broach the subject. She vehemently denied ever having agreed to such and, knowing her character so well, I believe her wholeheartedly.
We set about challenging the apparent untruth that I was told. Firstly we requested my aunt’s medical notes from her hospital stay. Secondly, I helped my aunt to contact her MP Alun Cairns, who wrote to the Cardiff and Vale Health board in September requesting them to remove the DNR from her records. One month later, a reply came from the consultant with whom I had apparently spoken over the telephone, as follows:
‘The decision that cardio-pulmonary (CPR) resuscitation should or should not be attempted if an individual patient suffers a cardiac arrest (i.e their heart stops beating) is a clinical decision made by the medical staff. Outside of certain medical conditions, the changes of a successful outcome are very low and there is a very high risk of permanent, life-changing, disability in survivors. Where possible, decisions regarding escalation of treatment, such as CPR, in the event of a patient deteriorating are discussed early in the course of a hospital admission. A competent adult can refuse any offer of treatment. The converse, however, does not apply. The decision that CPR is not appropriate is documented in the medical records using a DNACPR [do not attempt cardiopulmonary resuscitation] form. This form is not signed by the patient since it is a clinical decision. The form does document the date and time of the decision and records discussion with the patient and their relatives. The decision of the appropriateness of CPR can be reviewed and would usually be reviewed should a further hospital admission become necessary.’
An offer was made that, following lifting of restrictions, an appointment could be made for my aunt to speak with the consultant in person. However, it should have already been apparent to staff that my aunt is housebound due to mobility issues, so this was in effect out of the question.
The next step in the process was to request a review by the Public Service Ombudsman for Wales. In due course, the decision was relayed to us as follows: ‘The Ombudsman found that the decision about the appropriateness of CPR would usually be reviewed upon a further hospital admission. She [my aunt] had been informed that the DNACPR did not mean she would not receive all active treatment for a presenting condition and, if she was readmitted, she could make her wishes clear to the admitting team that she wished to be resuscitated. Regarding the removal of the DNACPR from the medical records, the Health Board were correct in saying that the medical records were legal records which could not be altered in any way. The Ombudsman found no failings. However, in acknowledging her concern about readmission to hospital, the Ombudsman considered whether there was anything further that could be done to alert staff to review the DNACPR. The Health Board agreed to put a note on the Clinical Portal, the electronic records and Mrs X’s paper records.’
So, there you have it, in case you are not aware of the law surrounding this issue. To be fair, it’s not a straightforward subject, as discussed in this BMJ article which questioned in 2017 whether change was needed regarding this somewhat controversial approach. New advice for clinicians was issued in 2020 on both NHS Wales and England’s websites following a landmark legal case ongoing since 2014.
Last year the Daily Mail highlighted that the lack of guidance accessible to families has led to a proliferation of poor and unlawful practice during the pandemic. This would include more than sixty DNRs doled out upon those with learning disabilities during 2020. These were carried out incorrectly or without proper consultation with patients or carers.
As Dr Max Pemberton has pointed out in the Mail, DNRs are being ‘issued on a seemingly cursory basis’ to over-65s; sixty-five being the age above which one is issued a ‘frailty score’ by the NHS. This was established in 2017/8 when the NHS England became the first health care system in the world to identify those living with moderate and severe frailty.
How cruel, then, that there are those whose records are tainted with a non-removable – though possibly subject to review – DNR during the latter years of one’s life. Perhaps it is indeed time for change on this issue because already I sense that my aunt is blocking all possibility from her mind that she will ever come home from hospital again.