And now the new NHS Scotland Guidelines (CPR)

The new NHS Scotland Guidelines
on Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) at:

Yesterday we took a look at the excellent guidelines from the General Medical Council. Guidelines which are largely non-partisan, legally precise, and greatly clarify good procedure when non-resuscitation is being considered.

At just over 40 pages (compared to the GMC’s 80+), the NHS outline has the advantage of brevity. It has a number of good points in making DNR (or DNACPR as it is now called) more understandable, both for those that can benefit from it and those that might not. And it opens the door for uniformity of practice across Scotland. But the extent of its muddled thinking means that another 40 pages could easily be expended clarifying, for those presumably who don’t know already, exactly what it does mean.

The NHS document claims to be in line with the GMC one. There are some admirably simple areas – such as when CPR is defined with a minimum of technicality. But there is confusion over fundamental areas.

Readers of this blog will no doubt look for what it has to say about advance directives or ‘living wills.’ While we maybe all ‘know’ what the writers of the document mean, this is hardly an excuse for getting important differences mixed up.

For instance, there are (whatever name given to them) directives: legally binding instructions from the patient to the medical team.

Then there are statements: general expressions of values and wishes that can be used for guidance rather than being legally determinative. Both are useful in different ways, so understanding which is which can definitely help.

In its Glossary, NHS Scotland turns definitions somewhat on their head (as well as incorrectly citing statutory provisions south of the border: It defines an Advance Directive or Advance Decision as:

“A statement of a person’s views about how they would or would not wish to be treated if the patient loses capacity. This can be a general statement about, for example, wishes regarding place of residence, religious and cultural beliefs and other personal values and preferences as well as about medical treatment and care.” And goes on to say that these are , “Known in England as an Advance Decision to Refuse Treatment (ADRT).”

This is the antithesis of what is actually the case. The England & Wales provision for an Advance Directive is most definitely not a ‘general statement’ (even though general statements of values can be added). It is a very specific direction as to what treatment should not be given if certain circumstances arise. Such expressions in Scotland, validly made and applicable in the circumstances that subsequently arise, derive similar if not identical legal persuasiveness from parallel legal principles.

This NHS Scotland error is compounded by calling the Scottish equivalent of a ‘Directive’ a ‘Statement.’ But one can hope that all concerned would see through such abuse of the English language and understand the basic difference in practice

What is more of a problematic, given that one could reasonably by forgiven for looking to such a document for guidance, is the sadly disingenuous approach to proxies. The bureaucracy to have a person of your choice authorised by a court to speak on your behalf in health matters, is considerable. There are still any number of advantages from doing so, but the precise powers of such a welfare guardian are determined by a court. For general treatment decisions, or generally consenting to treatment, few problems can be envisaged. But authorising a proxy to refuse potentially life-sustaining interventions carries other questions, and the court will probably have to satisfy itself – in advance – that it was in the patient’s best interests. This poses a situation that could be too controversial for a simplistic answer. To imply the existence of such a simple mechanism to ensure refusal of CPR, unless that really is the case, might be considered far from transparent or helpful.

Studies throw much doubt on the ability of proxies to accurately judge what a patient would have wanted when it comes to a complex medical scenario. Yet giving a proxy carte blanche would undoubtedly simplify the doctors’ dilemma and satisfy many activists. Rather than argue for or against such provisions in principle, the starting point must be to determine whether they already have practical existence in reality. (Exit is seeking further clarification from NHS Scotland on this.)

The GMC suggests that the wishes of a proxy should be taken into consideration. But NHS Scotland appears to go further, listing a proxy’s refusal of CPR as a valid reason for not giving that treatment. Desirable or not, should such practice become routine, it would be a major digression.

One excellent if small innovation, is a set of procedures to ensure DNACPR forms are accessed by emergency care staff. This means that if you are transferred from one institution to another, the DNACPR instructions, whatever they are, should be followed.

A DNACPR form (formerly a DNR instruction) is not the same as a living will. This is made clear in the Guidelines. If it is not possible to anticipate cardiac or respiratory arrest – for instance, if the patient is presently in good health – then an advance directive / living will is appropriate, and mention of refusing CPR in certain circumstances (that have yet to arise) can be made there.

A DNACPR, on the other hand, is completed at a much later stage, by both doctors and patient, and formalises the protocols under which CPR will not be started. Once completed, copies of both documents should be kept readily accessible.

The chances are that things will proceed as normally, with increased confidence in CPR decisions, and shortcomings of the NHS Scotland document will be ignored or updated in due course. The flowcharts and DNACPR forms are admirable, as is the good will of so many people behind the collaboration. It certainly represents a mammoth effort by many health boards and our concerns should not overshadow its excellent intentions.

More resources

Outcome from one month’s cardiac arrests in Scottish hospitals

Slide show of the development of the NHS Guidelines (Powerpoint)
Press & Journal article
Place of death from cancer
NHS health library on euthanasia, refusing treatment, palliative care and living wills
NHS multi-faith resource inc stuff on death attitudes
Making an advance decision about medical treatment (England & Wales quick guide)
Scottish Executive on Advance statements
The NHS document May 2010
The GMC document May 2010
GMC response to NHS document at consultation stage
Adults with Incapacity (Scotland) Act 2000

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