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Hospital violated patient's rights with 'do not resuscitate' order, court rules Hospital violated patient's rights with 'do not resuscitate' order, court rules
(about 3 hours later)
The family of a woman who died in one of Britain's best-known hospitals have won their claim that her rights were violated when an order not to attempt resuscitation was put on her medical records without her being consulted.The family of a woman who died in one of Britain's best-known hospitals have won their claim that her rights were violated when an order not to attempt resuscitation was put on her medical records without her being consulted.
The case of Janet Tracey, a care home manager who died at Addenbrooke's hospital, Cambridge, underlines a legal duty of NHS bodies to consult patients before making such "do not resuscitate" (DNR) decisions, according to the family's legal team.The case of Janet Tracey, a care home manager who died at Addenbrooke's hospital, Cambridge, underlines a legal duty of NHS bodies to consult patients before making such "do not resuscitate" (DNR) decisions, according to the family's legal team.
Merry Varney of the legal firm Leigh Day, representing Tracey's husband David, said: "The judgment sends a clear message to all NHS Trusts, regulatory bodies and healthcare professionals that patients have a legal right to be informed and consulted in relation to decisions to withhold resuscitation." Merry Varney of the legal firm Leigh Day, representing Tracey's husband Dave, said: "The judgment sends a clear message to all NHS trusts, regulatory bodies and healthcare professionals that patients have a legal right to be informed and consulted in relation to decisions to withhold resuscitation."
Doctors and nurses have professional guidance on the issue but health trusts in England also decide their own policies on how the decisions are made. The family has argued that many are confusing and do not include any information for patients and their families. Doctors and nurses have professional guidance on the issue but health trusts in England also decide their own policies on how the decisions are made. The family argued that many are confusing and do not include any information for patients and their families.
David Tracey said after the court of appeal judgment: "We're all so pleased that the court has agreed that imposing a 'do not resuscitate' order on Janet without consulting with her was unlawful. Nearly seven in 10 people die in hospital and 80% of those die with so-called DNR or DNAR notices in place. Cardiopulmonary resuscitation, attempting to restore breathing or blood flow to critically-ill patients, is often a violent process with rib fractures and brain injury significant risks. But although the law makes clear the final word on such issues lies with medical staff, there has been an apparent lack of clarity over just how far they have to go in consulting a patient with mental capacity or their families about their wishes.
The British Medical Association, Royal College of Nursing and the Resuscitation Council had begun a review of their joint professional guidance well in advance of Tuesday's judgement and the results are expected to be approved within weeks.
Dave Tracey said after the court of appeal judgment: "We're all so pleased that the court has agreed that imposing a 'do not resuscitate' order on Janet without consulting with her was unlawful.
"It feels as though the wrong done to Janet has been recognised by the court and the fact that her death has led to greater clarity in the law gives us all some small comfort."It feels as though the wrong done to Janet has been recognised by the court and the fact that her death has led to greater clarity in the law gives us all some small comfort.
"We hope that the strong message to all doctors, that there is a legal duty to consult with patients before imposing a DNR, will prevent any other patient and their family going through our experience.""We hope that the strong message to all doctors, that there is a legal duty to consult with patients before imposing a DNR, will prevent any other patient and their family going through our experience."
Varney said: "The belief such information would cause distress is no longer a sufficient reason not to inform and consult with a patient. There must now be convincing reasons to displace this right.Varney said: "The belief such information would cause distress is no longer a sufficient reason not to inform and consult with a patient. There must now be convincing reasons to displace this right.
"The court's ruling should now bring an end to the unwelcome surprises that not only Janet and her family endured, but also others across the country have suffered, when they discover a decision has been made to withhold resuscitation without any information or consultation.""The court's ruling should now bring an end to the unwelcome surprises that not only Janet and her family endured, but also others across the country have suffered, when they discover a decision has been made to withhold resuscitation without any information or consultation."
Tracey, who was 63, broke her neck in a car accident soon after she had been diagnosed with terminal cancer. She died in March 2011. The judgement will have profound implications for patients, their families and medical staff, even though it made clear that courts should be slow in issuing general guidance on how DNR decisions are made.
Healthcare inspectors and the health ombudsman have previously expressed concern about the way some DNR orders are made.
Janet Tracey, who was 63, broke her neck in a car accident soon after she had been diagnosed with terminal cancer. She died in March 2011.
Cambridge University Hospitals NHS foundation trust (CUH), of which Addenbrooke's is part, said it was "considering the implications of this judgment and the next steps very carefully".Cambridge University Hospitals NHS foundation trust (CUH), of which Addenbrooke's is part, said it was "considering the implications of this judgment and the next steps very carefully".
Its chief executive, Dr Keith McNeil, said: "Today's ruling hinges on a specific point of law. There was no criticism of our clinical care.Its chief executive, Dr Keith McNeil, said: "Today's ruling hinges on a specific point of law. There was no criticism of our clinical care.
"It is a fact of life that every day people die in hospitals. From my own experience as a specialist hospital doctor, the most important thing is that these patients are treated with the utmost respect and dignity."It is a fact of life that every day people die in hospitals. From my own experience as a specialist hospital doctor, the most important thing is that these patients are treated with the utmost respect and dignity.
"End-of-life situations involve doctors and nurses having emotionally challenging but necessary conversations with patients and their families about what happens in the final stages of their care."End-of-life situations involve doctors and nurses having emotionally challenging but necessary conversations with patients and their families about what happens in the final stages of their care.
"Medical staff use a combination of their compassion, experience and judgment at these difficult times to try and find the right pathway for each individual patient, and provide the support needed for everybody involved.""Medical staff use a combination of their compassion, experience and judgment at these difficult times to try and find the right pathway for each individual patient, and provide the support needed for everybody involved."
Dave Tracey's lawyers have always insisted the case was not about a right to demand to be resuscitated but about whether a patient has the right to know how DNR decisions are made and be consulted before they are made.
The case centred on how the first of two DNRs was placed on Janet Tracey. It was cancelled five days later after it was challenged by her family. David Pannick, QC for the trust, had argued in court that though there was a "general desirability" to consult, "a caring doctor" might well have spared Tracey a discussion which was going to cause distress for no good reason.
Lord Dyson, the master of the rolls, rejected arguments that a failure to consult Tracey or her family did not breach article 8 of the European convention of human rights.
"A decision as to how to pass the closing days and moments of one's life and how one manages one's death touches in the most immediate and obvious way a patient's personal autonomy, integrity, dignity and quality of life."
But Dyson said the court should be slow to give general guidance as to the circumstances in which it was not appropriate to consult a patient in relation to a DNR decision.
The judgment added that when it came to a decision "which will potentially deprive the patient of life-saving treatment, there should be a presumption in favour of patient involvement" and convincing reasons would be needed not to involve them. The trust had not demonstrated these.
In his view, "doctors should be wary of being too ready to exclude patients from the process on the grounds that their involvement is likely to distress them", although he also recognised the "difficult issues which require clinicians to make sensitive decisions sometimes in very stressful circumstances."
The court found that since Janet Tracey's death, the trust had put right shortcomings in the ease with which patients could access its policy on DNRs. Dyson also rejected the Tracey family's claims that there should be a mandatory national DNR policy for all healthcare organisations in England.
"It would probably be impossible to devise a scheme which is completely free from difficulty," he said. "The problems generated by decisions whether or not to impose DNACPR ['do not attempt CPR'] notices are inherently fraught … Whether it is appropriate to consult will depend on a difficult and sometimes controversial judgment to be made by the clinicians."
The judge said: "No doubt all NHS trusts will take note of this litigation and take account of the outcome of the appeal … It is not self-evident that a central mandatory policy would necessarily be more effective. The real difficulty facing clinicians in individual cases would remain whichever course was adopted."
The Resuscitation Council said the judgment "emphasises the importance of clinicians documenting clearly their reasons, should they decide not to discuss a DNACPR decision with a patient or explain it to them."
Its chairman, David Pitcher, said effective communication with patients and families was crucial. Doctors and nurses must not allow a default position where people who did not wish any attempt to be made to resuscitate them were unable to state their case clearly.