An Open Letter to the Chairman of the Association of Ambulance Chief Executives

An Open Letter to the Chairman of the Association of Ambulance Chief Executives

Dear Dr Marsh,

I was very pleased by your recent letter to me (5 May 2015), because it made it obvious that the AACE is aware of at least some of the things 'within contemporary 999 behaviour' which concern me. I am in the process of compiling something quite detailed, which I think will probably be sent to the AACE within the next fortnight, but I wish to point something out in this 'stand-alone' letter.

Almost all of the recent investigations into what could be termed 'systemic behavioural failings' within the NHS (for example, the Francis Report into Mid Staffs) have stressed, as part of their conclusions, that 'the situation cannot be adequately improved without a 'Culture Change''. The response, is usually some 'follow-up recommendation' (for example, the LACDP 'advice' in response to the Neuberger report) which attempts to explain 'what good thinking and behaviour would look like' (to use my own phrase). All very admirable - but the real question, is HOW TO ACHIEVE such 'culture change'.

I was discussing a piece his organisation has recently published with Simon Chapman, and I said something like 'I agree with the objectives you outline, but you seem to be using 'soft arguments' as the reason for change: why do you not use legal arguments where they exist ?'. Simon said he didn't quite understand what I was getting at, so I sent him the example of 'clinicians usually write that 'patient confidentiality' stands above the logical requirement of section 4(6) of the MCA' but the law doesn't actually seem to support that position - section 3(4)(b) of the MCA can be used as 'the proof'. The argument is outlined in my piece at:

http://www.bmj.com/content/348/bmj.g4094/rr/703333

Simon then understood the point I was making: but he also didn't think it likely that the material his organisation was publishing, would (to use my phrase) 'dig deeply into legal argument'.

I don't dislike 'softer arguments' - the second part of my piece above, presents a 'softer argument' after the legal argument of its first part - but I am FIRMLY of the opinion, that the FASTEST and MOST CERTAIN way of 'changing culture', is to make clear that 'what you are doing at the moment, would probably be found illegal, if it were judged in a court case'.

Most clinicians 'argue over ethics', but I insist that we should all be 'arguing from law': although law and ethics are inter-linked, people are charged with acting contrary to law - courts use 'law' and only professional bodies concentrate on 'ethics'. I can illustrate where my approach differs from that of most clinicians, by showing part of the AACE's letter to me.

My question 2 was this:

The recent Montgomery ruling has made it crystal clear that 'consent' and 'application' are distinct concepts for treatments: clinicians as a body can legitimately judge the competence of the application of a treatment, but clinicians are not to judge the acceptability of their own behaviour with regard to 'consent'. What I want to know, is whether your AS's paramedics adopt the position that family carers are to be trusted by default (in other words, that before the word of a 'deeply involved' layman is to be disbelieved, there must be evidence of a lie) ?

So, if a relative calls 999, and tells your paramedics 'My husband explained to me last night that he definitely no longer wants CPR if he is in arrest - we were going to explain this to the GP during a planned visit tomorrow, but we have not told the GP yet ...' then WOULD YOUR PARAMEDICS ATTEMPT CPR OR NOT ?

The answer in the letter from AACE was:

Question 2

Relating to whether our paramedics would attempt resuscitation or not

We do agree that family and carers should be believed without any evidence or justification of a perceived lie or malicious intent. Providing the person concerned has evidence of end of life - and it is genuinely believed that resuscitative efforts would most likely be futile or not desired - then we would recommend not to commence CPR.

A CPR decision such as a DNACPR form (do not attempt resuscitation), an advanced decision to refuse treatment, an advance statement or expression of wishes, notification of beliefs and values and views of those closest to the patient are of course all helpful, and provide supportive information to help aid the decision.

QUESTION and ANSWER END

I asked question 2, because the AACE had told some Members of Parliament::

'Without a DNACPR form or information that establishes that a person is at the end of life, resuscitation may be the course of action decided upon by the clinician that may be later seen as unethical, inappropriate and most importantly not what the patient would have wished for.'

The AACE are using 'unethical' as the strongest of their arguments, in that description. A few years ago I described the 'rules for CPR' in a single page, and I used a LEGAL argument, to cover the same issue that the AACE are talking about:

'If it is believed that CPR might restore life, then if the quality of that restored life might be deemed acceptable by some patients - even a very small minority - the usual ethical principles apply. In such a situation, it is for the patient himself to have judged whether the outcome of CPR would be acceptable, and for the patient to indicate his decision: which clearly must have been done, in advance of the CPA itself. This is usually described as PATIENT AUTONOMY, and a mentally capable patient, once informed of the clinical consequences of accepting or refusing an offered treatment, instructs the clinician whether or not to proceed with the treatment.

For CPR, the rule is that if a clinician is aware of information which would persuade a reasonable person, that the patient would have refused CPR for the CPA in question, had the patient somehow been able to consider the issues relevant to his CPR decision during a CPA and also to indicate his refusal, then the clinician must not attempt CPR. If a clinician attempts CPR, and a third party believes the clinician should have concluded that the patient would have refused resuscitation had the patient been capable of doing so during the CPA, the clinician is running a risk of prosecution for assault.

If the clinician is not reasonably persuaded that the patient would have refused CPR, then CPR should be attempted.'

As it happens, I also included on my single page description of 'the rules for CPR', something Robert Cole, a senior WMAS paramedic with whom I was discussing these issues ca 2010, wrote in one of his e-mails to me:

'We are a long way from doing this (although I would!!) But at least we are beginning to agree .. Resus in my opinion is just a clinical intervention like any other skill and should not be seen as a mandated right by health care professionals .. After all if we were not called it would not have been done!! The simple answer is to ask why were we called and how can we help!'

Yours sincerely, Mike Stone

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