A Criticism of the BMA/RCN/RC(UK) Joint CPR Guidance

I'll elaborate on my earlier:

'If the patient is mentally-capable and CPR could be clinically successful, it isn't a case of ' there must be a presumption in favour of involvement of the person in the decision-making process'. Section 4(5) of the MCA almost certainly [I'll perhaps explain 'almost' in a later addition - but you can remove that ''almost certainly' if you wish to] requires that 'CPR must be offered' in this situation. And it is then SOLELY the patient's decision whether to FORBID a future CPR attempt'

Our law has now settled on genuine Informed Consent - that is actually described by section 3(1) of the MCA, and the Montgomery court case seems to have established Informed Consent UK-wide (and, Montgomery 'implied that informed consent was the case even as far back as the late 1990s'). And Informed Consent isn't 'shared decision-making' - the clinicians do the informing of the clinical factors, then the patient does the deciding.

There is an exception, if getting the decision from the patient, would be damaging to the patient (which will probably be a rare situation, in the opinion of our judges): but it isn't 'a presumption in favour of involvement of the person in the decision-making process' as this guidance says, it should be 'there is a presumption that the patient will be making the decision'.

See David Oliver's article at:

http://www.bmj.com/content/352/bmj.i1494

and the series of comments to that article at:

http://www.bmj.com/content/352/bmj.i1494/rapid-responses

for some discussion of these recent court cases: perversely, Dr Oliver argues that judges telling doctors they must discuss CPR with patients, will result in less and worse discussion !

I wrote in the original piece, in 2):

'The guidance is somewhere between disrespectful and offensive towards family and friends who are involved with patients'

That is the only conclusion I can draw, while 999 paramedics look towards the records, and want to do things such as 'checking that the signatures on an ADRT refusing CPR are not forged', instead of believing what family carers are telling them. I made my anger at this very clear in a recent BMJ piece at:

http://www.bmj.com/content/353/bmj.i2230/rr-7

As it happens, I also described informed consent in that piece, but with regard to 'disrespectful and offensive towards family and friends who are involved with patients' I wrote in that piece (titled 'Michael H Stone: A defence of my preference for law and not ethics'):

If my [hypothetical] 82 years old, but seemingly 'healthy', father had made it very clear to me that under no circumstances would he want CPR to be attempted, I might not think he was making the 'right decision' but I would respect it because it is his life, and he would experience the consequences if he arrested and CPR was attempted - if he collapses, I tell 999 paramedics that he had made it clear to me that he would never want attempted CPR but the paramedics attempt CPR, 'then I'm not happy with the ethics of 999'.

When EoL patients are at home, and capacity has been lost, discussions about 'what should happen' can lead to disputes, for example between a GP and a family carer. The only thing I am 100% certain of, is that a family carer's 'well, I'm not going to do that, because my dad made it perfectly clear to me he would have refused [that course of action]', is legally (and in my opinion morally) correct. It has to be legally correct: because it follows the fundamental 'a person is sovereign over his or her own body' legal principle. There is no such clarity, once 'professional ethics' [and professional objectives] are applied to disputes between relatives, clinicians and police officers: and while 'arguing the ethics' with a GP is one thing, 'arguing with police officers about ethics' is a wholly unsatisfactory experience (for a live-with relative), immediately after a death, and when 'the police officer is confused'.

I consider the CPR Guidance to be confusing in places, and legally flawed in others: it is so divergent from what I would write, if I combined my understanding of the Mental Capacity Act with my family-carer perspective, that I find it hard to express my objections. Which is why I end up going on at such length.

But, it is fairly easy to explain why I object to this section - this is on page 20:

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It is important to understand that a personal welfare attorney is not empowered to make decisions on behalf of a patient regarding whether or not CPR will be attempted, unless their power of attorney document states specifically that the personal welfare attorney has the power to consent to or refuse life-sustaining treatment (which would include CPR). It is likely (although this has not been tested by the courts) that in such a case the attorney can make an advance decision that CPR should not be attempted. Such a decision should be recorded on the CPR decision form or equivalent.

If the welfare attorney makes that decision, it is a binding decision that clinicians must respect, unless:

• the circumstances of a cardiorespiratory arrest are not those envisaged when the advance decision about CPR was discussed with and made by the welfare attorney, or

• the clinician has good reason to believe that the decision made by the welfare attorney was not made on the basis of the patient's best interests.

A deputy does not have such a power, nor does any other person close to the patient.

Where there is disagreement between the healthcare team and an appointed health and welfare attorney or court-appointed deputy about whether CPR should be attempted in the event of cardiorespiratory arrest, and this cannot be resolved through discussion and a second clinical opinion, the Court of Protection may be asked to make a declaration.

More information about welfare attorneys, deputies and the Mental Capacity Act can be found in the Mental Capacity Act code of practice37 (see page 23 for decision-making and legal representatives flow chart).

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I'll explain my objections as they occurred, when I read that.

'It is likely (although this has not been tested by the courts) that in such a case the attorney can make an advance decision that CPR should not be attempted.'

Patients can make - and write down - Advance Decisions to refuse CPR: and this type of patient-expressed decision is covered by sections 24-26 of the MCA.

A Welfare Attorney most definitely CANNOT make such an 'advance decision' - what a welfare attorney can definitely do, if it can be done at all, is to make a best-interests decision for DNACPR in advance of a CPA. This CPR guidance spends much time ENCOURAGING such 'anticipatory DNACPR decisions' and it most definitely supports the idea of the making of 'anticipatory best-interests DNACPR decisions' and of their recording in a written form. It FOLLOWS that if there is a question about [the legality of] anticipatory best-interests DNACPR decisions made by welfare attorneys, much of the guidance in this document is also in doubt.

As I have pointed out in a BMJ piece, if a welfare attorney makes such a best-interests DNACPR decision, the attorney's signature should be the signature on any DNACPR documentation:

http://www.bmj.com/content/352/bmj.i26/rr-5

Moving on, we find:

'If the welfare attorney makes that decision, it is a binding decision that clinicians must respect, unless:

• the circumstances of a cardiorespiratory arrest are not those envisaged when the advance decision about CPR was discussed with and made by the welfare attorney, or

• the clinician has good reason to believe that the decision made by the welfare attorney was not made on the basis of the patient's best interests.'

Now, AS A PATIENT I would be appointing a welfare attorney to make the best-interests decisions: AS AN ATTORNEY I would have accepted that making those best-interests decisions was my responsibility to the patient.

Clinicians might feel that a welfare attorney's decision is flawed - and a relative or friend I might take issue with a clinician's decision/position re 'best interests' - but

'If the welfare attorney makes that decision, it is a binding decision that clinicians must respect, unless the clinician has good reason to believe that the decision made by the welfare attorney was not made on the basis of the patient's best interests.'

is NOT what the law states.

And the rules (these are very clear in the MCA) are these.

From the MCA itself:

6(6) Section 5 does not authorise a person to do an act which conflicts with a decision made, within the scope of his authority and in accordance with this Part, by-
(a) a donee of a lasting power of attorney granted by P, or
(b) a deputy appointed for P by the court.

6(7) But nothing in subsection (6) stops a person-
(a) providing life-sustaining treatment, or
(b) doing any act which he reasonably believes to be necessary to prevent a serious deterioration in P's condition, while a decision as respects any relevant issue is sought from the court.

Those sections of the Act are covered in the Code of Practice (a document which I am less than happy with !) in 7.29:

7.29 Attorneys must always follow the Act's principles and make decisions in the donor's best interests. If healthcare staff disagree with the attorney's assessment of best interests, they should discuss the case with other medical experts and/or get a formal second opinion. Then they should discuss the matter further with the attorney. If they cannot settle the disagreement, they can apply to the Court of Protection (see paragraphs 7.45-7.49 below). While the court is coming to a decision, healthcare staff can give life-sustaining treatment to prolong the donor's life or stop their condition getting worse.

This joint guidance implies that a welfare attorney's best-interests DNACPR decision can be disregarded if a clinician has serious doubts about it - all the law says is that in such a situation, WHILE A COURT RULING IS BEING APPLIED FOR, CPR can be attempted.

I'll illustrate - I've just noticed this particular flaw in the Code - why the Code is problematic. Immediately after section 7.29 (which is legally correct) we can read section 7.30 - and 7.30 is not legally correct:

7.30 An attorney can only consent to or refuse life-sustaining treatment on behalf of the donor if, when making the LPA, the donor has specifically stated in the LPA document that they want the attorney to have this authority.

Nobody - not welfare attorneys, nor anybody else - 'consents' to a treatment during mental incapacity. Nobody 'refuses' a treatment, either, during incapacity. 'Consent and Refusal' are things which patients do during capacity (and patients can project forwards into anticipated future incapacity) - best-interests decision-making REPLACES the concept of 'consent' during mental incapacity.

What happens, is the treatment 'is offered': so, the clinicians would inform the attorney that if the patient arrested, CPR might be clinically successful. The attorney then considers the two situations of CPR being attempted, or not attempted, and the outcomes of these two alternatives, in the context of section 4 of the MCA, and the attorney would then say (or write down) 'DNACPR is in the patient's best interests' or 'attempting CPR would be in the patient's best interests'. THAT IS NOT 'CONSENTING TO' 'offered CPR'.

Another fairly obvious way of thinking about the incompatibility of 'consent' and best interests, is to consider the situation of the clinicians making a best-interests decision - if the concept of 'consent' applies during best-interests decision-making, then the clinicians would be making the decision, and also consenting to their own decision (which is absurd).

This is still in this latest version of the CPR guidance, and (see my BMJ piece mentioned earlier) I still disagree with it:

'Some healthcare professionals have suggested that adult patients should sign CPR decision forms, in a similar way that patients provide signed consent to treatment, such as an operation. This is not a legal requirement. Such a policy could be an obstacle to effective end-of-life care for some dying patients for whom discussions about CPR decisions will be potentially harmful and unnecessary. There is no requirement for those close to patients to sign forms to confirm their agreement with/to a DNACPR decision. Asking them to do so could contribute to them inferring incorrectly that they are being asked to make the decision. It is common for those close to patients to misinterpret or forget precise detail of what they are told at such times, when they are understandably anxious and often tired. For this reason it is crucial
that healthcare professionals document details of such discussions and explanations clearly in the patient's health records.'

And the final two sentences, are still as logically stupid as they were when I complained about them a couple of years ago.

'It is common for those close to patients to misinterpret what they are told at such times, when they are understandably anxious and often tired. For this reason it is crucial that healthcare professionals document details of such discussions and explanations clearly in the patient's health records.'

That is ABSURD - if the healthcare professional suspects 'misinterpretation' of the conversation, it is the duty of the HCP to check on that, and then if necessary to explain the situation again.

And the best way to be sure such a misunderstanding has not taken place, is for whoever (this would be the layman involved, if the clinician wrote the note of the conversation: or vice versa) did NOT write down a description of the conversation, to read the written description and the to either sign it to say 'I agree this is what we discussed' or to write down 'this isn't what we discussed - in my opinion the conversation went ...'.

On page 8:

1. a person who is at an advanced stage of dying from an irreversible condition, so CPR is contraindicated

2. a person who has advanced illness and deteriorating health such that CPR will not work

3. a person for whom CPR is a treatment option with a poor or uncertain outcome

4. a person for whom CPR is quite likely to restore them to a quality of life that they would value.

In the first two of these CPR will not be successful and should not be offered or attempted. This should be explained to the patient unless to do so would cause them harm. In the third and fourth, the wishes of the patient are paramount.

SORRY - 1 and 2 are not identical. It isn't clear that CPR 'should not be offered or attempted for 1'. Suppose that a patient who is indeed nearing death, realises he needs to make a new Will: if he asks for CPR to be attempted until he has completed his new Will, the question is no longer 1 - it is the question in 2 of 'would CPR not work [in extending his life so that he might be able to complete his new Will] ?'.

As for 3 and 4 - not the wishes of the person, the DECISION of the person.

Also on page 8:

The concept of treatment escalation planning is being used increasingly, particularly in hospitals, to plan and focus on what interventions a patient will or will not receive. Consideration of such choices as 'treatment options' can be perceived by patients and healthcare professionals as being a more positive approach than a predominant focus on decisions about which treatments to withhold, including DNACPR decisions.

While this could well be true, it is LEGALLY THE SITUATION that a person can forbid future interventions (ADRTs). This puts refusal of possible interventions on a different legal footing than 'interventions the patient would want'. And crucially, once the patient becomes mentally incapable, a valid and applicable ADRT REPLACES 'best-interests decision-making' - which is NOT TRUE of any statement about 'an intervention the patient would want'.

From page 9:

Unfortunately, it is inevitable that there will be situations in which advance care planning has not taken place - for example when an unconscious or acutely ill person presents as an emergency. When such planning has not occurred and a crisis results in acute or emergency hospital admission, the need to support the patient in reaching a decision, or to make a swift decision in their best interests, is forced upon healthcare professionals. They may not have met the patient before and may have limited information about his or her clinical condition, personal circumstances, views and beliefs. Furthermore the patient may not be well enough to participate fully in a process of shared decision-making.
These situations can present particular challenges for healthcare professionals making decisions about CPR.

My first point, is that 'shared decision-making' is a deeply unsatisfactory term, and should be discarded.

http://www.bmj.com/content/349/bmj.g4855/rr/761712

http://www.bmj.com/content/353/bmj.i2452/rr-3

http://www.bmj.com/content/353/bmj.i2452/rr-15

http://www.bmj.com/content/353/bmj.i2452/rr-17

The second of those BMJ pieces, was one of mine pointing out that our law on consent is NOT a description of 'shared decision-making'. The third of those is by Amali Lokugamage, Consultant Obstetrician and Gynaecologist, who writes:

'This type of analysis is most welcome and I agree with Stone's rapid response, that ultimately the patient gets to make the final decision, and that those decisions take precedence over everything. It is not just the inclusion of patient's values and beliefs in shared decision making within the construct of evidence based medicine. So the term shared decision making is not correct when a human rights caveat is applied to clinical guidelines.'

The fourth of the above links goes to another response within the same series (very interesting - it is worth looking through all of the responses), by Sithira D Pathberiya, Paralegal, and it includes:

'While I agree with Stone's recent response on obtaining consent, providing relevant information in an understandable manner can be burdensome and time consuming. However society has come far enough to regard the right to bodily integrity and obtaining consent as important. Society is unlikely to part with these concepts as with parting with the concept of democracy, in favour of despotism or even technocratic models. Should time for consultation not be adequate, then is it not the consultation times that need to be increased in order to meet the standard of care required and reduce the burden on care providers?'

My second observation, is that having agreed with me that 'when an unconscious person presents as an emergency at a hospital the healthcare professionals probably will not have met the patient before and may have limited, or no, information about his or her clinical condition, personal circumstances, views and beliefs', this guidance does not agree with me about the obvious consequence of that. The 'obvious conclusion' is that those hospital clinicians CANNOT apply section 4(6) to their own decision-making: which in my opinion means 'those clinicians CANNOT defensibly make an MCA best-interests decision'. Unless your decision-making involves an understanding of the patient as an individual, in my opinion it is not actually a decision made within the framework described by section 4 of the MCA: put another way, any decision based solely on clinical outcomes, is not a genuine best-interests decision.

This poses a very interesting question indeed - you can find it as 'poser no 11' in my series at:

http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=692&forumID=45

There is more in the poser piece (including a small survey) but the 'interesting question' is this one:

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The legal defence of 'necessity' is based on 'justifiable ignorance'.

The legal protection the MCA offers to a decision-maker, is based on the application of an 'adequate understanding of the situation' and the ACQUISITION OF THAT UNDERSTANDING is an 'implied duty' within the Act.

If an unconscious patient arrives at A&E unaccompanied, necessity has to apply.

If an unconscious patient arrives at A&E accompanied by a family carer, the question is does the family carer's understanding of the situation make an application of 'necessity' inappropriate ?

If a patient who is on some sort of 'EoL register' collapses at home, and a family carer calls 999 to be more certain of the medical situation, isn't the family carer's decision about what should happen next (a decision, which the carer MUST defend in terms of the MCA's test - as a long-term carer for the patient, a failure to satisfy 4(9) of the Act 'would be negligence') logically 'better' than any decision made by a 999 paramedic which would be defended by 'necessity' ?

PUT SIMPLY, isn't a decision made by the person who understands the situation best (there, the family carer) the best decision available ?

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My next addition to this series, will be looking at the CPR Guidance in the context of my 'Alan and Liz' scenario.

I have a piece on BMJ titled 'It would be much simpler if techniques for CPR did not exist' at:

http://www.bmj.com/content/352/bmj.i1494/rr-3

In that piece, I point at my 'Alan and Liz' scenario (it is reference 4) and I introduce 'Alan and Liz' in this context:

'If a person arrests at home, then irrespective of the cause of the arrest [or of the probability of an arrest occurring], there is a very real possibility that if CPR is attempted there would be 'resuscitation but with significant brain damage' [because of oxygen-starvation of the brain]. This makes a decision to 'absolutely refuse CPR if I am home when I arrest' entirely reasonable and rational (a person could prefer the certainty of death, to the uncertainty of the outcome of attempted CPR), and it seems to me 'perfectly legal' to make that refusal - but (see 'Alan and Liz' in ref 4) all I can say is 'good luck to anyone who tries to do that' !'

The final paragraph on page 7 of the guidance, mentions the risk of brain damage and resulting disability if there is a delay between the arrest and the CPR attempt: which is what I pointed out in the BMJ piece.

Page 29 of the guidance, tells us:

As ambulance clinicians have to satisfy themselves that the document exists and is valid in the circumstances encountered, an agreed method of emergency communication of any such decision, and of the basis for it, is necessary and should be subject to clinical governance.

Where we viscerally disagree, is about the TRUST ISSUE: should attending 999 paramedics default to believing what family carers tell them. I would point out, that it is entirely possible to suffer a cardiopulmonary arrest (CPA) from a situation of mental capacity - so a patient could have created a written ADRT refusing CPR, changed his mind a little time before he subsequently arrested, and told his family carer that he had changed his mind. Even if there is no time to 'alter the document(s)' the MCA makes it clear that a written ADRT refusing CPR can be retracted verbally - and in this situation, the family carer would know the ADRT had been retracted. Until 999 paramedics DO BELIEVE family carers, we are in the situation I wrote about here:

http://www.bmj.com/content/350/bmj.h3181/rr

'Trust is indeed a two-way thing, and it is even harder to build 'trust' into the patient-system interaction, than for trust between a patient and an individual clinician [where the relationship is ongoing] to exist - but in this new 'social media age', it is logical to expect patients and relatives to increasingly share their own experiences of 'where the system did not 'trust me'', with the consequence that increasingly laymen will conclude 'that I cannot trust the system, if it is unwilling to trust me'.'

I went on to explain why as a layman I'm not happy with this reliance on 'what has been written down in official records-chains' in the same BMJ piece:

'This is a difficult one: I see the main impediments to 'greater trust' as probably being time pressure, the desire of individual professionals to cover their own backs [especially if they are 'out of their own comfort zone'], and the fact that trusting the laymen does equate to lessening the 'control' possessed by the professionals and the system.'

I'm not very happy with my 'lessening the control' phrasing - I should have written, I think, 'equate to a reduction in the 'control'' - but it gets the point across.

CORRECTION

There is pretty fundamental mistake - slip of the brain ! - in the original piece.

It SHOULD HAVE READ:

WHILE THAT (sentence) IS LEGALLY CORRECT, it DOES NOT EXPLAIN that a verbal of refusal [from a mentally-capable patient] of CPR DURING A SITUATION OF ONGOING CONTACT is EVEN MORE LEGALLY-BINDING than a written ADRT which refuses CPR. The problem is that a verbal refusal of CPR CANNOT BE A VALID ADRT [as defined in sections 24-26] REFUSING CPR - and, displaying a degree of logical incoherence which almost reduces me to tears, many clinicians believe (and write) that this means 'a verbal refusal of CPR is NOT legally binding'.

INSTEAD OF WHAT IT DOES SAY:

WHILE THAT (sentence) IS LEGALLY CORRECT, it DOES NOT EXPLAIN that a verbal of refusal [from a mentally-capable patient] of CPR DURING A SITUATION OF ONGOING CONTACT is EVEN MORE LEGALLY-BINDING than a written ADRT which refuses CPR. The problem is that a verbal refusal of CPR CANNOT BE A VALID REFUSAL OF CPR - and, displaying a degree of logical incoherence which almost reduces me to tears, many clinicians believe (and write) that this means 'a verbal refusal of CPR is NOT legally binding'.

Many apologies - I do try to proof-read my own stuff, but I'm hopelessly bad at it !

I rather casually commented in an e-mail, that I think Scotland is better than England at a lot of end-of-life things, but behind England in the respect of 'not having the Mental Capacity Act'.

Instead of including this 'explanation' in an e-mail I've decided to write it here, and to point my correspondent at it..

Although many (most ?) clinicians seem somewhat 'unaccepting' of this, in England the MCA has hugely 'tidied up' decision-making, and 'best interests'.

* the autonomy of mentally-capable patients, is explicit in the MCA: it is very clear that sections 3 and 25(4)(c) describe 'genuine Informed Consent'. They describe decision-making which falls to the patient alone, after clinicians have informed the patient about clinical factors;

* whatever 'best interests' means, its meaning must be CONTAINED WITHIN section 4 of the MCA (reasoning: section 6(6) of the Act, gives decision-making AUTHORITY over best-interests decisions to suitably-empowered attorneys and deputies - because attorneys and deputies can be laymen, and as laymen would NOT be familiar with 'historical' medical and legal concepts of 'best interests', the MCA has effectively made those historical concepts redundant [the essence of 'whatever the Act retains' of those historical concepts must be within the wording of section 4 - and it is, in 4(5) and 4(6)]. The alternative, is that the Act gives decision-making authority to people who could not correctly apply the Act - which would be an absurdity);

* having given attorneys and deputies authority over best interests in section 6(6), the MCA goes on in section 6(7) to tell us that this authority can only be 'ignored' in very limited ways, and ONLY WHILE A COURT RULING IS BEING SOUGHT. Their authority is given by a court - and it has to be challenged via a court.

So the MCA - if you pay attention to what it actually says - is clear about patient autonomy, clear that attorneys are appointed to MAKE any necessary best interests decisions, and clear that to challenge an attorney's decision a court ruling must be sought ('sought' as in 'applied for').

I am reluctant to unquestioningly accept that the BMA/RCN/RC(UK) guidance describes the law for Scotland correctly, having pointed out that in crucial respects it is wrong or misleading in its descriptions of the law for England - but if we assume the law is described correctly in the guidance, then the description on page 21 of the law in Scotland, is 'much messier' than my description above of the law in England:

Copied from page 21:

Where CPR may be able to re-start the heart and/
or breathing for a sustained period, and a decision on
whether or not to attempt CPR is based on the balance of
benefits against harms and burdens, the welfare attorney
or guardian must be consulted, and the view that they
take will have legal consequences as set out below. Where
there is disagreement between the healthcare team and an
appointed welfare attorney about whether CPR should be
attempted in the event of cardiac or respiratory arrest, this
should be resolved as quickly as reasonably achievable by
discussion and, if necessary, a second clinical opinion.
If the healthcare team wishes (in accordance with good
clinical practice) to make an advance decision to attempt
CPR should the need arise, they must, where reasonable
and practicable, obtain the agreement of the welfare
attorney or guardian. If the welfare attorney or guardian
agrees, attempting CPR will be lawful. If the welfare
attorney or guardian does not agree to attempting CPR, the
section 50 Adults with Incapacity (Scotland) Act procedure
will normally be invoked (a procedure for resolving such
disagreements) and the second-opinion doctor nominated
by the Mental Welfare Commission or, ultimately, the Court
of Session, will determine if it should be authorised. There
is justification for the clinical team to act in the face of a lack
of agreement by the proxy if a situation arises too quickly
for the section 50 procedure to have concluded, unless the
welfare attorney or guardian or other interested party has
obtained an interdict (court order) prohibiting CPR.

If the healthcare team wishes (in accordance with good
clinical practice) to make an advance decision not to
attempt CPR, where it is reasonable and practicable to do
so they should consult the welfare attorney or guardian
before completing a CPR decision form or equivalent. If the
welfare attorney or guardian agrees, a CPR decision form
or equivalent may be completed. If the welfare attorney
or guardian does not agree (i.e. they want the patient to
receive CPR), the doctor should consider their views and
may offer a second opinion. However, if the second opinion
concludes that CPR would not be successful, the welfare
attorney or guardian cannot insist on it, any more than a
competent dying patient could insist. The CPR decision form
or equivalent may be completed. It is more difficult if (having
taken account of the patient's previously expressed wishes)
the clinical team's conclusion is that CPR might work for the
patient who lacks capacity but, overall, would be more likely
to offer unacceptable (to the patient) burden than benefit. If
the welfare attorney or guardian thinks that CPR would, on
balance, be more likely to provide benefit than unacceptable
burden, the clinical team should seriously consider whether
to respect that view. If, ultimately, they conclude that CPR
cannot be justified, they should complete the CPR decision
form or equivalent, document their reasons, and explain to
the welfare attorney or guardian their right to take the matter
to court if they disagree.