This is a fictional dilemma compiled from the MDU's files.
The scene
A GP called the advice line to ask about an unusual request from a patient she had seen earlier in the week. The patient was in his forties with no serious medical concerns, and had attended about a minor skin condition - but while he was there, he asked the GP if she would fill out a DNACPR form for him.
This surprised the GP, and on exploring the issue it transpired that the patient had watched paramedics trying unsuccessfully to resuscitate his father. The experience had convinced him that he never wanted to undergo the same if his heart stopped. The GP had discussed the implications of such a decision, but the patient was adamant.
The GP had reviewed the DNACPR form with him, but because of the wording, she was uncertain if it was appropriate to complete it in these circumstances.
Our advice
The MDU adviser explained that in order for a patient to decline potentially life-saving treatment, and for this to be legally binding, certain criteria has to be met.
The Resuscitation Council (UK) explains that, "DNACPR decision is made and recorded to guide the decisions and actions of those present should the person suffer cardiac arrest, but is not a legally binding document."
On the other hand, an appropriately drafted advance decision to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 - England & Wales, is a legally binding document. For an ADRT refusing CPR to be valid, the patient must be 18 years old or above and make it while they have the requisite mental capacity to make the decision not to undergo CPR.
It should be in writing, signed and witnessed. The document must also state what specific treatments they do not wish to receive and in what circumstances their decision applies. In addition, it should include an explicit statement that the advance decision will apply even if the person's life is at risk.
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Regional differences
ADRTs are not underpinned by any legislation in Scotland and Northern Ireland, but are likely covered by common law.
The Resuscitation Council (UK) states that the principles that have been established in English cases would guide decision making in these two jurisdictions and sets out the factors that would mean an advance refusal would likely be valid in these areas. These are:
- that the person was at least 16 years old in Scotland and 18 years old for NI when they made the decision
- they had capacity
- the circumstances of leading to the need for CPR are those outlined in the document
- the person was not under any undue influence when making the advance decision.
in order for a patient to decline potentially life-saving treatment, and for this to be legally binding, certain criteria has to be met.
Resuscitation refusals - what to consider
When GPs are asked to help patients in making advanced decisions about refusing resuscitation, they should bear in mind the following points.
- You must have assessed the patient's capacity and be satisfied they have the necessary ability to make the decision.
- Patients need to be aware that the validity of an advance decision would be in question if they had subsequently acted contrary to the terms of their decision, or arranged a lasting power of attorney (LPA) for health and welfare who could make decisions about CPR for them.
- A patient cannot predict the future, so it's difficult to cover every eventuality in their decision. Where a patient is fit and well at the time of making the advance decision, it is very difficult to draw up a valid decision covering all the necessary specific circumstances.
- As such, it may be better for heathy patients to arrange a lasting power of attorney (LPA) for their personal welfare, which would include medical treatment. There would need to be a provision in the LPA confirming the attorney was authorised to make decisions about life sustaining treatment.
- The patient should be made aware of the possibility that an emergency may arise where their advance decision is not, or cannot, be brought to the attention of those treating them. They should also be told that if this is the case, and assuming the patient lacks capacity, treatment will be given in what is believed to be in their best interests.
- The patient may wish to have their decision recorded on a DNACPR form, as well as the ADRT, as these are easily recognisable. The likelihood of a decision being overlooked can be minimised by filing a copy in the GP records, hospital records, and with the local ambulance service.
- The patient can also make relatives aware of the document and keep a copy somewhere obvious in their home. They can then take this with them so it can be found on their person if they collapse in public.
Dr Ellie Mein
Medico-legal adviser
Dr Ellie Mein
Medico-legal adviser
MB ChB MRCOphth GDL LLM
Ellie joined the MDU as a medico-legal adviser in 2013. Prior to this she worked as an ophthalmologist before completing her Graduate Diploma in Law in Birmingham.
See more by Dr Ellie Mein