DNACPR decisions

Editor – Harrington, Price and Edmonds describe a quality improvement project of documentation and communication of do not attempt cardiopulmonary resuscitation (DNACPR) decisions via the use of an integrated electronic health records system.¹ However, it is inadequate to describe that the 2014 Court of Appeal in Tracey v Cambridge Uni Hospital NHS FoundationTrust & Ors ruled that Janet Tracey's human rights were breached simply as a result of a lack of communication of such a decision.²

Importantly, while simultaneously reinforcing the fundamental professional requirement not to harm, and that cardiopulmonary resuscitation (CPR) cannot be demanded whatever the patient's wishes, the Court of Appeal asserted that the human rights presumption for involvement in the decision. This involvement in a decision being a very different responsibility from the communication of a finalised one, requiring an open mind; the desire to understand and achieve wherever possible the wishes and preferences of the individual concerned; and consideration of the person's views in the final decision – which then needs to be communicated appropriately. There need to be convincing reasons not to involve the patient – patient choice would clearly be one, but distress alone would be insufficient, rather requiring a significantly higher threshold of psychological or physical harm. Ultimately, it is this involvement and knowledge of the final decision which then allows the person the opportunity to seek a second opinion if so desired.

Finally, the Tracey judgment should always be understood alongside the subsequent Winspear v City Hospitals Sunderland NHS Foundation Trust judgment and that if a person lacks decision-specific mental capacity at the time, the resulting best interests decision requires involvement, where practical and appropriate, with appropriate family / welfare attorney(s) irrespective of the time of day or night.^3,4