Guest Post by Joseph Bowen
Joseph is a BPhil Student studying at Oxford University.
Following a surprise inspection of Colchester General Hospital by the Care Quality Commission (CQC) on Friday 14th November, it was reported that inspectors had found that some patients (“elderly people, some [suffering from] dementia”) had been inappropriately restrained, and/or sedated without consent, and that ‘Do Not Resuscitate’ (DNR) notices were being disregarded. What struck me about this case is that, while all are horrible practices, the DNRs being ignored seemed worse than the inappropriate restraint and sedation without consent.
To begin with I would like to say that this post does not seek to condemn any of the staff’s actions all things considered; sitting in front of my computer now, I cannot even begin to imagine the pressure of working in an A&E and/or any other hospital ward – let alone an oversubscribed A&E ward as the CQC’s report found. That said, I am interested as to what’s behind my reaction to this case.
A DNR instructs health care professionals to withhold ‘Cardiopulmonary Resuscitation’ (CPR) and ‘Advanced Cardiac Life Support’ (ACLS) (and ‘Intubation’, where a tube is inserted into the windpipe to maintain an open airway, sometimes additionally indicated by DNI) were a patient’s heart to stop or were the patient to stop breathing. Where DNRs are sometimes understood as an ‘omission of action’ by patients and their families, some propose changing the term to the less emotively-charged ‘Allow Natural Death’. The DNR notice is brought about following a dialogue between the patient, their families, and healthcare professionals; where a patient cannot be involved in discussions it can be mandated by the patient’s family (more specifically, following recent changes, their ‘Health and Welfare’ power of attorney).
I think there are two possible types of wrong going on in these cases: a violation of the patient’s autonomy and a wrong on the grounds of harm. To begin with lets consider autonomy. In all three types of cases reported at Colchester General Hospital there has clearly been a violation of the patient’s rights; it goes against our autonomy (our right to determine or self-govern our lives) to be inappropriately restrained, sedated without consent, and for a DNR to be ignored. However, it seems whatever collection of rights a patient has, the right to choose when and how to die is of paramount importance (to be explicit, this is a right I think the patient should have).
The motivation behind my granting this right such importance in the context of DNRs is probably due to the current state of euthanasia in this country: the DNR may offer hope to some terminal patients. One way in which this could be understood is that, since the patient is denied the right to active euthanasia, more then rides upon the DNR being respected.
However, it could also be that the DNR may offer hope to some terminal patients in regards to alleviating harm. I have in my mind the picture of an elderly patient suffering from the later stages of dementia: the patient may have lost their ability to respond to what’s going on around them, to respond to conversation and to control their movement; they require constant care, in some cases not even being able to support themselves. Leaving rights violations aside, the DNR offers an opportunity to alleviate further suffering and harm.
There is a further element to alleviating harm: so far I have suggested that the harm to the patient can be stopped; however, what of their families harm? Again, I have the picture of the patient suffering from the later stages of dementia, but with a loving caring family around them, feeling helpless, unable to stop their loved one’s suffering. The family have, likely, first had to come to terms with the disease slowly taking their loved one from them; second, had to come to the decision (often between those family members granted power of attorney) that they now think a DNR is in their loved one’s best interest; but third, are denied this.
It may be asked of me: well which is it? Which factor makes the failure to respect a DNR so much worse than inappropriate restraint and/or sedation without consent? I think it is grounded upon a violation of the patient’s autonomy. Why? Because the right to choose when and how to die seems of upmost importance. That said, and as suggested, this may well be due to the laws currently surrounding euthanasia.
What I find so utterly horrible about the idea of a DNR notice being ignored is that the patient in my case of the dementia sufferer, the patient who has all but lost their autonomy, will likely be the last given the right to die – if ever – because of the inability of the patient to give informed consent or partake in assisted suicide. It may be pressed against me, how can one’s autonomy be violated when one doesn’t have any autonomy left? We could point to a living will or advanced directive of the patient (thanks to Luke Davies for pushing this point); here the patient has outlined their wishes and to violate the patient’s wishes would be analogous to being cremated after expressing wishes to be buried. The more interesting question is what happens when the patient never properly thought about DNRs or expressed their wishes. One would hope that the family would do what they think is best for their loved one, and so would be acting on behalf of the patient’s autonomy; to knowingly do otherwise would seem, again, to be a violation of the patient’s autonomy.
There is also the question of intervention of any sort for patients who are suffering from the later stages of dementia. As long as the person does not suffer more, because of lack of intervention, then perhaps some interventions should not be offered. Ignoring DNR can often distress the person and those who observe it with only improving the quantity of life rather than the quality of life. Sometimes professionals seem to give too much weight to the quantity of life rather than the quality of life.
I think you’re completely correct Sue (and thank you for your comment): the distinctive expertise of a medical professional is that, medical; it’s not necessarily expertise in a patient’s overall wellbeing (closely borrowed from Allan Buchanan’s ‘Social Moral Epistemology’). While that expertise is definitely needed to determine what is the best course of action to realise the patient’s overall wellbeing, it shouldn’t be determinate. And it seems this quantity versus quality speaks to this.
I am curious: Did the perpetrators face criminal persecution for these rights violations?
The QCQ is yet to publish their report and the hospital is replying with “No comment” when asked about these concerns (I am lead to believe – I haven’t actually asked them myself!) so as of yet I haven’t found any indications either way; I suppose the question is whether they should be, which I think leads nice to Chris’ question.
An interesting post Joseph – I’d never really thought about the wrongness of ignoring DNRs before now.
I thought I’d just note that at least part of what might be behind a practitioner’s violation of a DNR is a form of defensive medicine. That is, the decision to respect a DNR is irreversible (in that the person cannot later be brought back to life in case of a mistake), while choosing to ignore the DNR is, in at least one sense, reversible (since a patient sick enough to arrest and have a DNR order prepared is very likely to arrest again in the near future and can then be simply left alone). If close family or friends of the patient decide to object to the decision to respect the DNR (which is unfortunately not impossible), then the doctor is the first person to be held responsible for ‘killing’ the patient. On the other hand, if they object to the decision to ignore the DNR, it is rather harder to criticise someone for ‘saving’ their life.
This trickiness is also probably compounded by the fact that the emergency care health professionals attending to the patient in the case of an arrest are, due to the specialised fracturing of medicine, unlikely to be the same physicians who oversee the patient’s daily care and arranged the DNR. In many cases, they might even be seeing the patient for the very first time, and have no knowledge of the circumstances in which the DNR was arranged and what the patient’s justifications were. The “better safe than sorry” approach to resuscitating a patient is somewhat understandable in situations like these.
The asymmetry of (ir)reversibility is not plausible if one considers, say, the pain and suffering of the process to be real costs. Which of course they are. Once a person is forced through this process, that cost can never be undone. It has, after all, already been paid by the patient in experienced suffering.
The assumption that a life, once saved, can still be ended later also depends on whether it can actually be ended later.
If there DNRs can just be ignored, and suicide and euthanasia are prohibited and actively prevented, where is the guarantee that the “saved” life can later be disposed of?
What is the status of a person’s rights when someone can without punishment cut their throat open and stick a tube in it after they explicitly stated they never want this exact thing happen to them?
Thanks for your comments Chris (and thanks for replying on my behalf HT!): I think your thoughts Chris speak to the mitigation of culpability in a professional’s ignoring of DNR. But as HT has said, what worries me is that following a DNR being ignored, that act isn’t reversible: first, in that the patient and family had to go through the actual harm of having the DNR ignored; second, and more important (I think anyway), the patient then has to wait until “natural death” to have their further suffering alleviated. That said, there are obviously many other factors that weigh on the medical professional when making the decision, all things considered.
Concerning the DNR itself, a few clarifications may be necessary where I’ve not been clear enough: where the patient is resuscitated in situations where the living will, i.e., the DNR, can’t be taken into account then the health care professional is acting rightly when resuscitating, all things considered (since they couldn’t have known); but, in a hospital situation (and A&E may sit somewhere between the previous and following remark, depending on time constraints and/or the ability to access patient notes) I was under the impression (and I may be wrong – if I am please let me know!) that the DNR will be on the patient’s notes, and that the health care professionals will be aware of these notes. They will be (or should be, if they aren’t [and that may be a different claim]) aware in the same regard that they will be aware of allergies so as not provide the patient with a drug that they are allergic to.
Interesting post Joseph. Do you know if there was any evidence of the patients’ wishes or of advance directives in these cases of DNR orders not being respected. In practice, these orders are often made on ground of futility, but Dominic Wilkinson and I have argued that such judgements are best interpreted about distributive justice. If patients are denied medical treatment because of justice considerations and the limitation of resources, there is no need to get consent and autonomy does not come into it.
Apologies, at some point of converting my files I’ve lost the hyperlinks, please see below this comment for the main article I was in dialogue with. To try and repond nevertheless, the article suggests that this was the case, but it’s not yet been confirmed by the QCQ or Colchester General (i.e., our only evidence is journalistically confirmed). If I’ve understood you right, is yours and Dominic’s paper discussing DNRs being issued against families wishes? As here I was worried about a DNR being ignored after being made by the patient and/or family.
Referring to the practice of DNRs, I was under the impression that DNRs should be made in a dialogue between the patient and their family, and so advancing directives of their wishes. There are three things to say following this: (1) where a dialogue isn’t the case then I’m not as sure the rights violation is apt; (2) where dialogue is engaged with the patient, but treatment (and, loosely, ending life support treatment following a ‘crash’) is denied on a cost-benefit analysis (or in terms of distributive justice), then this discussion is framed differently from mine, and also an all-things considered judgement; (3) where the dialogue has happened and been realised through a DNR then I’d say it offers a prima facie concern on behalf of the patient (or, I may say it weighs for the professional’s culpability, but there *will* be other concerns).
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