Critical Care

Do Not Attempt Resuscitation orders: should you discuss with the patient?

The Court of Appeal has stated that a statement in a capacitous patient’s medical notes that resuscitation should not be attempted (a ‘Do Not Attempt Resuscitation’ Order – DNAR), should usually only be inserted after consultation with the patient: see R (Tracey) v Cambridge University Hospitals NHS Foundation Trust and others [2014] EWCA Civ 822 (17 June 2014).

The facts have been widely aired in the media: see, for example, here.

Mrs. Tracey had terminal lung cancer. Her clinicians indicated in the notes that no attempts at resuscitation should be made. Her family found out about this, and were outraged, saying that the DNAR order should not have been made without consultation with Mrs. Tracey. Their quarrel was not with the medical appropriateness of the determination that resuscitation would not be in Mrs. Tracey’s best interests, but with the procedure  - the failure to consult.  This, they said, violated Mrs. Tracey’s rights under Article 8 of the ECHR.

The Resuscitation Council, intervening, said that a requirement to consult with the patient would interfere with clinicians’ ability to deliver individual and compassionate care. A patient might, for instance, be very distressed by a discussion about a possible DNAR order.

The outcome can be briefly stated:

  • Mrs. Tracey’s Article 8 rights were engaged by recording the DNAR in the notes. This followed from, inter alia, Pretty v UK (2002) 35 EHRR 1.
  • Her Article 8(1) rights were violated by failing to involve her in the process
  • Article 8(2) required the policy adopted by a Trust in relation to DNAR orders to be sufficiently clear and accessible: see Purdy v DPP [2009] UKHL 45; [2010] 1 AC 345.
  • The absence of a mandatory national DNAR policy was not a violation of Article 8. Local policies would, if properly formulated, satisfy the demands of Article 8(2)
  • The concerns of the Resuscitation Council were real, but could be met by an important caveat: there should be consultation with the patient unless the clinician ‘thinks that the patient will be distressed by being consulted and that distress might cause the patient harm.’ Continue reading

Telling porkies

by Dominic Wilkinson (@Neonatalethics)

 

One of my registrars asked an interesting question this morning. A commonly used life-saving medicine in newborn intensive care is derived from animal products; should parents be told?

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Terminal Illness and The Right Not to Know

The parents of a young woman named Vickie Harvey, who tragically died at the age of 24 from acute myeloid leukaemia, have launched a campaign to give patients the right not to know that they are terminally ill.  Eric and Lyn Harvey claim that their daughter lost the will to live when, after her leukaemia returned following a period of remission, doctors told her ‘in graphic detail’ how she would now succumb to her disease. Eric Harvey told the Daily Mail:

After [Vickie was about her prognosis] she changed – and never really got out of bed again. We knew she was dying, but we feel that, if she hadn’t been told that day, she would have lasted longer’. Continue reading

The Texan flautist and the fetus

Imagine that when you woke up this morning, you found yourself lying next to an unconscious stranger. The stranger has a rare life-threatening illness, and unbeknownst to you he was plugged in to your organs during the night. You are now stuck to the stranger. If you disconnect the life support he will die. If, though, you remain connected to him for most of the next year his illness will have recovered, and he can safely ben unplugged. What should you do? Are you obliged to stay attached to the stranger? It might be generous of you to give up your body, and good if you choose to do so, but should we require you to remain connected?

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Should exceptional people receive exceptional medical treatment?

There are approximately 150,000 human deaths each day around the world. Most of those deaths pass without much notice, yet in the last ten days one death has received enormous, perhaps unprecedented, attention. The death and funeral of Nelson Mandela have been accompanied by countless pages of newsprint and hours of radio and television coverage. Much has been made of what was, by any account, an extraordinary life. There has been less attention, though, on Mandela’s last months and days. One uncomfortable question has not been asked. Was it ethical for this exceptional individual to receive treatment that would be denied to almost everyone else? Continue reading

Keeping pace?

If you receive an implanted pacemaker for your heart, does it become your property? When it is no longer any use to you (because you have died), do you have to give it back?

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‘Precarious (Bio)ethics: Research on Poisoning Patients in Sri Lanka’

On 9 May 2013, Salla Sariola, from ETHOX, gave a fascinating talk at the St Cross Ethics Seminar, based on work done collaboratively with Bob Simpson (Durham). The presentation focused on the large number of self-poisonings which have been taking place in Sri Lanka, often using lethal agricultural pesticides and herbicides unavailable in many developed countries. This presentation is now available as a podcast at the bottom right of the Oxford Uehiro Centre main webpage. Continue reading

What happens when you die

I have just watched someone die. Just one person. But a whole ecosystem has been destroyed. Everyone’s roots wind round everyone else’s. Rip up one person, and everyone else is compromised, whether they know it or not. This is true, too, for everything that is done to anyone. Death just points up, unavoidably, what is always the case.

This is trite. But it finds little place in bioethical or medico-legal talk. There, a human is a discrete bio-economic unit, and there’s a convention that one can speak meaningfully about its elimination without real reference to other units.

In some medico-legal contexts this is perhaps inevitable. There have to be some limits on doctors’ liability. Hence some notion of the doctor-patient relationship is probably inescapable, and the notion requires an artificially atomistic model of a patient.

But ethics can and should do better. Continue reading

Nine to five philosophers

Owen Barfield was lunching in C.S. Lewis’s rooms. Lewis, who was then a philosophy tutor, referred to  philosophy as ‘a subject’. ‘”It wasn’t a subject to Plato”, said Barfield, “It was a way.”’1

It would be dangerous for a modern professional philosopher to say that her philosophy was her ‘way’. I can well imagine the responses. ‘She’s lost objectivity’. ‘She’s a preacher, not an academic.’ ‘Most of us  were disabused in our first week as undergraduates of the childish notion that philosophy was about the meaning of life. She obviously missed that lecture. She was probably at a prayer meeting instead.’

For the scoffers, philosophy is a job. It’s something they do from nine to five. Then, when they leave the faculty, they walk out into the world of angst and bereavement and sick children, and begin, without reference to the day job, to try to puzzle out the meaning of the world and of their own place in it. The job, often, is about exactitude – about ensuring that every step in an examined argument is unimpeachably rigorous. But stop and ask them whether, as a result of the rigour, the argument can now be relied upon to change conduct, and they’ll stop, scratch their heads, and look at you as if you’re simple.

I’m not really accusing them of hypocrisy – of failing to judge themselves by their own standards. For an allegation like that to stick you’d have to show that they knew that the world of the day job was the same as the world outside. The problem is that they don’t perceive the two worlds as having any connection at all. The diagnosis is non-integratedness. It would be unkind to translate it as lack of integrity.

Recently I was reading Charlie Camosy’s book Too expensive to treat? Finitude, Tragedy and the Neonatal  ICU2. It’s rather a good book, but its contents aren’t the point for the moment.

Charlie and I don’t always see eye to eye. He’s a Catholic, for a start, with far too much respect for old dead men for my comfort. But the tone of the book struck me. Here was someone doing philosophy because the answers mattered. He’d unfashionably remembered that ‘philosophy’ means the love of wisdom. He approached the issues reverentially but insistently, determined not to let them go until he knew that they had something useful to say to  an artificially ventilated child.

No, this doesn’t mean that the book is a Catholic polemic; or that he’s mainly interested in crafting an argument that accords with the ruling Encyclicals; or that he’s trying to ensure his back will be covered when he next slinks into a confessional;  or that it’s a set of inevitable inferences from a set of a priori assumptions; or that it’s humourless, earnest,  preachy or fanatical. Let alone correct. It’s just a book by all of someone, with the intention of deriving principles that  apply to whole, real, humans, rather than to an abstracted portion of a human, or a pastiche of a human. It’s written to appeal to reason, conscience, intuition and hospital accountants, rather than to the Chairmen of grant-giving authorities and tenure committees. It’s the work of someone with a conjoined personal and professional life. That should be unremarkable. It’s actually very unusual.

That it is so unusual is a big problem both for philosophy and philosophers.

[Conflict of interest: Charlie Camosy is a friend. Come to think of it, that's hardly a conflict of interest. He wouldn't stop being a friend if I hadn't written this, won't be more of a friend because I have, and I won't be getting a cut of any book sales this blog might generate.]

References

1. C. S. Lewis, Surprised by Joy, Geoffrey Bles, 1955

2. Eerdmans, 2010

Patient L’s Autonomy

‘Patient L’ is a man in a vegetative state, under the care of Pennine Acute Hospitals Trust. The Trust has placed a Do Not Rescuscitate order in his notes, yet his family claim that he himself would want to be revived if his condition deteriorated, because of his faith in Islam. The court of protection has now decided in favour of the Trust.

The Trust’s claim is that it is in Patient L’s best interests to be allowed to die, whereas Patient L himself – if we are to believe his family (and there seems little reason not to) – would almost certainly disagree. Continue reading

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