Patient doesn’t want CPR
‘Business Dilemmas’
Dr Kathryn Leask
A private GP asks for advice about signing a DNACPR form. Dr Kathryn Leask gives her response
Dilemma 1
What to do about her request?
My patient has a friend who is disabled after being resuscitated
QI am a private GP. A 40-year-old female patient has asked me to sign a DNACPR form for her, as she does not want to be resuscitated in the event of a cardiac arrest.
She has no health problems and has capacity to make her own decisions about her care. She is adamant she would not want to be resuscitated due to the risk of permanent disability.
Her reason for making this request now is that she has witnessed a friend of a similar age, who was also previously fit and well, having a cardiac arrest associated with having Covid-19, who now has severe physical and intellectual disabilities.
I have discussed with her that there are many reasons why a person may suffer a cardiac arrest, some of which are treatable with a potentially good outcome.
I have also advised the patient that any such event is likely to occur in an emergency setting where those present may not know what her wishes are, meaning that attempts at resuscitation are likely to be made until more information became available.
Please could you advise on the best course of action?
A A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision is not legally binding, but is intended to be a guide for the decisions and actions of those who may be present when a person suffers a cardiac arrest or sudden death.
The GMC states that making and recording a DNACPR decision in a patient where a cardiac or respiratory arrest is expected and resuscitation is unlikely to be successful ensures that the patient dies in a dignified and peaceful manner.
DNACPR decisions may also be appropriate where CPR might be successful in returning spontaneous circulation and breathing, but where the benefits may not outweigh the risks and burdens.
Where a clinical decision is being made about the appropriateness of a DNACPR, this should be discussed with the patient, if possible, so that their preferences and wishes can be taken into account.
When a patient’s wishes to make provisions for their future care should they lose capacity to make decisions for themselves, a Lasting Power of Attorney (LPA) for health and welfare is more appropriate. The patient can complete the forms themselves using the Office of the Public Guardian website or obtain professional advice from a solicitor.
Completion of this allows the patient to appoint a deputy to make decisions for them if they are no longer able to make decisions for themselves.
In addition to the LPA, a patient can also arrange an Advance Decision which can include information about what treatment they would or would not want in the event of a cardiac arrest.
Unlike a DNACPR, a valid LPA and Advance Decision would be legally binding. While a patient may ask their GP to act as a certificate provider for their LPA, confirming the patient understands the content and implications of it, they would be advised to seek appropriate legal advice when drafting an advance decision to ensure its validity.
Dr Kathryn Leask is a medico-legal adviser at the MDU
Coercion is a form of abuse
Dr Sissy Frank
Domestic abuse has sadly been on the rise in lockdown. Dr Sissy Frank discusses what to do if you suspect domestic abuse
Dilemma 2
Husband may be controlling her
Q I have just had a remote consultation with a patient who described feeling low, tearful and anxious all the time as well having general aches and pains.
At first, I thought she may be feeling low due to the ongoing pandemic, so I asked her about her home life and support network.
She explained that she no longer speaks to most of her friends and family members. as her husband does not like them.
As her private GP. I am concerned that having no contact with her family and friends is resulting in her being extremely isolated at an incredibly challenging time.
Additionally, when I asked her to book a follow-up appointment, she explained that she had to check with her husband before doing so.
I am concerned that she may be subject to domestic abuse within the home.
What should I do?
A It is estimated that in the UK, 1.6 million women and 757,000 men were subjected to domestic violence and abuse in the year ending March 2020.
According to the Office for National Statistics, there has been an increase in demand for support services for those affected by domestic abuse during the pandemic.
This could be due to people in lockdown spending more time in their homes and it is becoming more difficult for individuals to leave the home or to access available support services such as attending counselling.
However, doctors are often able to identify people who may be affected by domestic abuse, so it is important that you are able to spot possible signs and be aware of your duty to safeguard patients and to maintain confidentiality.
Understandably, patients may be unwilling to disclose that they are suffering abuse or are at risk of harm. Clinicians should bear in mind that domestic violence and abuse includes controlling or coercive behaviour in an intimate or family relationship.
It is beneficial for staff and clinicians to be trained to explore these issues sensitively with the patient if possible.
Your practice should also have a policy for managing cases of suspected domestic abuse, and this should include a named senior person to liaise with local services for victims of domestic abuse and the creation of a care pathway that facilitates access to such services.
Dr Sissy Frank is a medico-legal adviser at the MDU
