Care homes warned to discuss 'do not resuscitate' forms with families

The NHS has warned GPs treating thousands of patients in care homes to follow the law and good practice on issuing "do not resuscitate" forms after apologising for not discussing the issue with a patient or his family.

The "reminder" followed investigations into a complaint by the daughter of a 77-year-old man after she found out by chance that he had such a form in his medical notes. The GP and staff at the home for people with physical disabilities and long-term medical conditions in south London where he was staying did not consider the man to have the capacity to be involved in the decision – a verdict the family strongly disputes.

Officials investigating the case said staff were "extremely sorry that they did not make more strenuous attempts" to speak to his daughter, who is next of kin and lives in Las Vegas. The GP was also sorry that she "became aware of this decision in such a blunt manner".

Andrew Eyres, managing director of NHS Lambeth, told her: "Whilst it is important that doctors do not place the burden of decision-making on close relatives, you have made us aware it is important to try and involve relatives even if they live abroad and are only able to visit their family member infrequently."

He was "grateful" to her for raising the issue "as it is an opportunity to ensure all doctors in south-east London who look after residents in care homes are aware of the legislation and good practice requirements in this challenging area of practice". The form saying the man should not be resuscitated was removed but the man's family have been told

there may be moves to reinstate it.

The NHS apology is likely to make care homes across England look carefully at policies and guidance relating to life and death decisions, as watchdogs have already told hospitals to do.

Eyres's response to the daughter's complaint was made last September, and coincidentally followed publicity surrounding legal action by the family of a woman who died at Addenbrooke's hospital, Cambridge. In that case, David Tracey alleges unlawful issuing of notices to medics not to attempt cardio-pulmonary resuscitation (CPR) on his wife, Janet, in the event of cardiac arrest. The notices are known as DNR (do not resuscitate) or more accurately DNAR (do not attempt resuscitation) forms.

Tracey is taking the trust running the hospital and the health secretary, Andrew Lansley, to court claiming breaches of human rights, an allegation both deny. The family wants the health department in England to ensure a national government policy on the issue rather than leaving it to professional guidance and local NHS bodies.

Other families have contacted the Guardian in recent months about what they consider to be breaches of the law or good practice in what is becoming a highly contentious and delicate issue. Although professional bodies say doctors have the final word on whether they should not attempt resuscitation where they believe it would be futile, their guidance makes clear that it is good practice to speak to patients and relatives where possible.

In the London case, Eyres told the family: "In a care home setting, CPR has a very small chance of successfully returning the patient to their previous state of health. If successful, there is a high risk that the patient will suffer rib or sternum fractures as well as internal organ injuries. If consciousness is regained, there is a risk that the patient will be left with brain damage and not regain their pre-morbid level of health."

"Because of these concerns, it is considered a mark of good practice that consideration is given to whether patients requiring long-term residential care and support would benefit from a CPR attempt in the event of a cardiac arrest. These decisions need time and careful consideration and are best not left to an emergency situation."

The man's daughter said she would advise anybody with a relative in long-term nursing care to check whether a DNAR form had been placed in their file without their knowledge.

She found the form – dated 17 March 2010 – when she visited her father last summer. She has passed a copy to the Guardian. It did not record any conversation with the patient or a welfare attorney, nor state the reason why a decision had been reached without such a discussion.

In the space for a summary of communication with the patient's relatives or friends a doctor filling out the form had written: "In America."

The man's daughter said: "I was shocked when I originally discovered it in my dad's file. My father does wish to be resuscitated because, he says, 'life is precious'. He wishes to be given access to life-saving treatment if that becomes necessary. It appears, however, that patients and their families have no rights in this matter.

"I have years of experience as a speech and language therapist, working with patients with a range of neurological, medical and cognitive impairments. I fully understand the risks of failed resuscitation attempts. My father has no terminal or progressive health conditions, and has a good quality of life and is happy."

NHS South East London said it was unable to comment on individual cases because of patient confidentiality. "We always deal with any complaint as swiftly and thoroughly as possible to ensure our patients, their families and friends are getting the best possible care," it said in a statement. "If there is ever concern over a complaint response we invite people to contact the parliamentary and health service ombudsman for further investigation."

The doctor involved also cited patient confidentiality but added that her practice took resuscitation decisions "very seriously, working as part of a multi-disciplinary team, within agreed practice policy and taking current local guidance into consideration". The charity managing the care home referred questions to the primary care trust.


Sourced from The Guardian, 6th May 2012.