Reality is a complex, slippery and very perspective-dependent concept
Professor David Oliver has recently written a piece called 'Resuscitation orders and reality' on BMJ:
http://www.bmj.com/content/352/bmj.i1494
There is also a discussion connected to the article, which you get to by clicking on the tab labelled 'Responses' - the direct link is:
http://www.bmj.com/content/352/bmj.i1494
I like David Oliver - he believes in the NHS and he is trying to improve healthcare (although this doesn't necessarily mean that we invariably 'see eye to eye' when we swap e-mails [and I think, the complication is 'where we are standing']).
David believes that two recent court ruling ('Tracey' and 'Winspear') which [and I'm using language 'a little loosely' here - that is almost always true, if you wish to stick to the main thrust of law] 'tell clinicians that they must discuss CPR with patient or family/friends EVEN IF the clinicians believe that CPR could not restart the heart' is likely to lead to (quoting from his article):
'I strongly predict that some staff, motivated by genuine concern for patients, will continue to make them "DNACPR" without family discussions. More court cases will arise. More patients will be "For CPR" until they're on a ward and a discussion can be had, perhaps days later. Crash teams will be called to patients' bedsides, wonder what they're doing there, and end up feeling obliged to start CPR.'
David sent in a response [to the earlier responses] and he wrote:
'Nonetheless, my piece was about the imperfect world we work in and potential problematic consequences of the ruling.'
My point is, 'the world depends on where you are standing'.
David writes in his article that:
'Many patients will lack the immediate capacity for that discussion. Some will have relatives with them to discuss CPR. Others may not, so we must discuss on the phone, or in person despite transport or distance. It's often hard to get hold of people or their numbers, even in emergencies.'
This is true - but why does the 'prototype Emergency Care and Treatment Plan' (recently consulted on at the RC(UK) website) have space for only ONE Welfare Attorney's contact details ?
Why do the current 'core specifications' for EPaCCS, INSIST ON 'the identification of a single 'main [family] carer'' ?:
In David's response he tells us:
'Second, there will be major pressure especially when patients are moving from A&E or AMU to a ward to say "are they for ressus" doctor? Often from Nurses who need to know how far to escalate and who are the constant presence for grim attempts at CPR and rightly wanting to avoid misguided attempts.'
This is an interesting question, in terms of my 'standard analysis' - I like to start with the situation of a terminally-diagnosed patient, who is at home, with a family carer living in the same home, and with the patient retaining mental capacity until something like a collapse or an arrest (a CPA) occurs. In this situation, the patient can make and express decisions about refusals of potential treatments WHENEVER HE DECIDES TO. So my issue, is that while CPR might still be clinically successful, the answer to the nurse's question of "are they for ressus" is WHATEVER THE PATIENT HAS SAID (assuming that CPR could potentially be successful - the patient has an absolute right to forbid CPR, and section 4(5) of the MCA implies that clinicians will offer CPR if it could be clinically successful).
But, it seems that [and this is despite all of the guidance, telling end-of-life patients that they should explain their decisions and wishes to their clinicians and families] if a patient explains a decision, such as 'I would definitely not want CPR to be attempted - if my heart has stopped beating, I want to be left to die', to a live-with relative, SOMEHOW THAT DOESN'T COUNT (unless the conversation has been recorded/verified by a GP or nurse - and, of course, GPs and nurses are not usually present in the patient's home) . It is quite difficult to prove this 'beyond doubt' because nobody really 'collects the evidence', but it is clear that the 999 Services do not default to 'asking the family carers what is going on and believing what they are told' - instead, 999 paramedics tend to 'trust the records as opposed to what carers tell them'. My own experience, when my mum died, was of 'being disbelieved because 999 wanted material written down by the GP' - see the following for 'my experience':
But I am not alone, in considering that too many clinicians 'look at the written records' - which, FOR CARE AT HOME, 'EXCLUDES FAMILY CARERS FROM BEING 'FULL MEMBERS' OF THE PATIENT'S SUPPORT TEAM' - because a doctor recently wrote in an e-mail to me:
'Another question is - why don't paramedics/doctors/nurses in an emergency situation trust family members to advocate for patients who lack capacity? How have we got to a position where professionals worry about being sued if they don't attempt CPR on pretty much everybody unless there is a red form waved at them? I would argue that this is because law has trumped ethics, and fear has trumped common sense.'
The problem, is that 'common sense' isn't 'common': what strikes a relative, GP, nurse, 999 paramedic and police officer as 'being common sense' isn't 'common' at all !
Most doctors like to 'use ethics' whereas I see only 'law' as useful if lay carers are involved (because live-with relatives are bound by the law, but cannot be expected to even understand medical ethics). It strikes me that 'it is obvious' that section 4(9) of the Mental Capacity Act is a legal duty, not a legal power - it directly follows that the idea that relatives 'cannot make decisions about whether a treatment should be withheld' is untrue (what is true, is that unless a relative is either a Welfare Attorney or a Court Deputy, the [best-interests] decision a relative makes cannot be 'imposed on others' - but, so far as I can see, doctors cannot impose their [best-interests] decisions on relatives, either):
Both 'reality' and 'what looks like common sense' depend on 'where you are standing':
http://www.bmj.com/content/352/bmj.i26/rr
And David Oliver and I, 'are standing in very different places' - I think that is the main reason, for any differences we seem to have.