The number of ‘do not resuscitate’ (DNR) notices being imposed without consultation is now a national scandal. What will the BMA do about it?
It is, on the face of it, encouraging that there has been such widespread, and such critical, reporting of the case of a Down’s syndrome patient who is taking legal action against an NHS trust after a “do not resuscitate” (DNR) order was put on his medical file without his knowledge or the knowledge of his next of kin. It instructed staff not to perform resuscitation in the event of a cardio or respiratory arrest. It also gave his disability as the sole reason for its imposition.
The 51-year-old man (referred to as AWA) was admitted to the Queen Elizabeth the Queen Mother Hospital in Margate, Kent, on September 7 last year. Despite daily visits by his family and carer and meetings between his parents and the clinicians, it was only when the patient returned to his residential home that the DNR order was discovered.
As I say, this case has been well reported, and at least on the BBC Radio 5 Live breakfast programme (which I tend to listen to when John Humphrys is on the Today programme — Nicky Campbell is both fairer and better informed) with a horrified reaction, as though this kind of thing is so dreadful it must be, surely, a rare occurrence in this country— unlike, one might suggest as a contrast, Holland, where an official report has showed that in one year, Dutch physicians deliberately and intentionally ended the lives of 11,840 people by lethal overdoses or injections – a figure which accounts for 9.1% of the annual overall death rate of 130,000 per year. The majority of all euthanasia deaths in Holland are involuntary. Lethal overdoses or injections are very much worse than simply not resuscitating, of course: and we’re nowhere near being there in this country, yet. But a DNR notice, if involuntary, is well on the way to euthanasia. That’s why the assumption that this is a rare event would be reassuring, if true. But is it?
The answer is that the case of “AWA”, on closer examination, turns out to be not so rare as one might hope: it is, indeed, the tip of a large iceberg. Consider the case of a woman who was allowed to die last year in Addenbrooke’s hospital, Cambridge, and whose husband as a result took its management and the then Health Secretary Andrew Lansley to court, alleging an illegal and repeated use of DNR orders. Doctors twice put such orders in his wife’s medical notes, cancelling the first after she objected to it only to put in a second three days later without her consent or any discussion with her, as a result of which she was allowed to die without any medical intervention. Or what about the case of a woman who died in the Central Middlesex Hospital whose son discovered, in his own words, “that a do not resuscitate (DNR) notice had been placed in her file. None of the family knew anything about this, and we never knowingly signed anything like this on my mother’s behalf, nor would we have done.”
Such cases are in fact commonplace:
An investigation undertaken by the Care Quality Commission (CQC), an official watchdog, found in October last year, based on spot checks of 100 hospitals, that involuntary DNR notices are being routinely applied, without consultation with patients or relatives, to elderly patients.
On one ward, one third of DNR orders were issued without consultation with the patient or their family, according to the NHS’s own records. At another hospital, junior doctors freely admitted that the forms were routinely filled in by medical teams without the involvement of patients or relatives.
Action on Elder Abuse, an independent charity, carried out its own analysis of the CQC’s inspection reports (the CQC itself having been less than frank about the implications of its own findings). Its findings uncover widespread evidence that patients are being regularly left to die without any medical intervention, without families knowing that decisions to do so have been taken.
Documented cases include the following:
· Inspectors who visited Queen Elizabeth Hospital, run by University Hospitals Birmingham Foundation trust, found no evidence that any of the patients whose files were marked DNR had been informed about the decision, nor their relatives told. The hospital’s own audit showed that in one ward, 30 per cent of cases did not involve any such conversations.
· At University Hospitals Bristol Foundation trust, there was no evidence that a DNR order placed on a patient had been discussed with the person or next of kin. A junior doctor told inspectors that they did “not tend to discuss” such decisions with families.
· At Royal Shrewsbury Hospital, run by Shrewsbury and Telford Hospital trust, a patient was labelled as DNR based on old medical notes from a previous admission – despite the fact that their health had improved.
· Asked how decisions to make such orders were made, staff at Royal Devon and Exeter NHS Foundation trust gave an example of an elderly person on the ward with health problems judged to make “resuscitation less appropriate”. The doctor involved did not know if the patient or an advocate had been asked for an opinion, or told that the notice had been imposed.
· At Conquest Hospital, run by East Sussex Healthcare trust, incomplete DNR forms were placed on patients’ files – without their involvement, or the two doctors’ signatures required to validate them. They were then being acted on as though complete, and patients had been left to die as a result.
The simple fact is that far from being rare or unusual, as Nicky Campbell — who was rightly shocked yesterday morning by the case of “AWA” — seems to have assumed, the widespread abuse of DNR notices has assumed the proportions of a national scandal. While actual euthanasia is still illegal and likely to be prosecuted (unlike in Holland, where there is an agreement that it will not be) this is the nearest the medical profession can get to euthanasia here without too much risk of prosecution.
The fact is, however, that involuntary DNR notices are illegal. AWA is taking legal action: but this ought to be a case for the Crown Prosecution Service. I know our doctors are wonderful and that we should all be grateful to them and that we are all delighted they are so well paid now. But some of them do have a tendency towards a certain professional arrogance. A prosecution or two wouldn’t do the profession any harm. Failing that, why doesn’t the BMA do what it’s supposed to be there for? What about one or two of the worst offenders being struck off? Pour décourager les autres? That might just do it.
