DNR – do not resuscitate
DNR MEANS ‘do not resuscitate’. The use of those words or, alternatively, ‘allow natural death’ (AND), is intended to convey to a medical team that a person whose heart has stopped or who has stopped breathing does not wish cardiopulmonary resuscitation (CPR) to be performed or to be incubated. The DNR request may be stated by the patient through an advance directive, a living will, or the family of the patient may instruct the medical team (it is important to note that a DNR order or statement does not imply that any other forms of treatment are withheld).
Cases in which patients’ wishes are not known and cannot be ascertained force medical teams and family members to engage in very sensitive and often heart-rending conversations that no one wishes to have. On one hand, CPR “involves chest compressions, delivery of high-voltage electric shocks across the chest, attempts to ventilate the lungs and injection of drugs” that could have side effects such as rib fracture with low probability of recovery. On the other hand, if CPR is not done, there is risk of brain damage. What a dilemma!
On the legal side, there are many issues, and the case of Tracey v Cambridge Unit Hospital NHS Foundation Trust & Ors [2014] EWCA Civ 822 addressed some of them. The English Court of Appeal found that doctors at Addenbrooke’s Hospital, in which Janet Tracey was a patient, had violated Article 8 of the European Convention on Human Rights (right for respect for private life) by failing to consult her before placing a DNR order on her medical notes.
Tracey had been diagnosed with terminal lung cancer with a life expectancy of nine months. Two weeks later, she suffered a serious cervical fracture in a major car accident. She was placed on a ventilator to address respiratory problems. About one week after, the doctors reviewed her condition and decided to take her off the ventilator, and in the event that she suffered cardiorespiratory arrest, a DNACPR notice was completed by the doctor and placed on her notes.
When Tracey’s family learnt of the notice, they objected and it was cancelled. However, after discussing her condition with members of the family, they agreed that a second DNACPR notice be placed on the notes. Tracey died only days later.
In the court action, it was contended (among other things) that the first notice violated Tracey’s human rights. Both at first instance and on appeal, it was held that Article 8 had been violated and, importantly for us in Jamaica, the duty to consult the patient or her family was found to also be a common-law duty. As stated by one judge, taking the patient’s feelings and interests into account “is integral to the respect for the dignity of the patient”.
In terms of the guidance to medical teams, the court’s ruling confirms that patients have a legal right to be informed and consulted in relation to decisions to withhold resuscitation. Of course, this does not eliminate the concerns by medical teams about the psychological harm and distress the discussion may cause when the message is that CPR will be futile. Ultimately, the legal right to be informed does not give patients the right to CPR.
For persons who agree that this is an important issue that demands public attention, let us begin the dialogue.
Sherry Ann McGregor is a partner and mediator in the firm of Nunes Scholefield DeLeon & Co. Please send questions and comments to lawsofeve@gmail.com or lifestyle@gleanerjm.com.