THE Royal Blackburn and Burnley General hospitals have admitted that patients and families have not always been involved in important discussions about ‘Do Not Resuscitate’ orders.
As a result some patients have received CPR, which is used to restore breathing, when this was ‘possibly inappropriate’ say hospital chiefs.
The medical profession believes resuscitation can cause unnecessary suffering.
And one health champion also said he had received complaints from patients and families who said Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions had been made without their knowledge.
East Lancashire Hospitals NHS Trust (ELHT) has ordered extra training for staff after bosses found talks over resuscitation were ‘not always occurring with the relevant patients’.
The orders instruct doctors not to attempt CPR if a patient’s heart stops.
ELHT said it did not know the number of cases where resuscitation was not discussed, as it did not collect the data.
Professional guidance has stated the orders should only be used after discussions with the patient or their family, and this has now become a legal duty following a landmark judgement in the Court of Appeal last week Russ McLean, chairman of the Pennine Lancashire Patient Voices Group, said he has been contacted by a number of patients and families in the last year who complained about a lack of consultation over DNACPR decisions.
He added: “More and more patients have been telling me about this issue and I actually raised it with the trust last year.
“The court judgement may have only come last week, which makes it a legal duty, but there have still been clear ethical guidelines around this which should have been adhered to by everyone at the trust.
“I think any patient or family member would have expected to be involved in the decision as a matter of course. Doctors seem to have taken quite a cavalier attitude and I find it absolutely disgusting that discussions have not always been happening.”
However, he praised the trust’s chief nurse Christine Pearson for highlighting the issue in her monthly report to board members, saying that it suggested a more open and candid approach from bosses. Mrs Pearson wrote: “Discussions were not always occurring with relevant patients and if they were there was no clear evidence of the discussion.
“Documentation generally appeared inadequate with old forms being used and decisions not being clearly visible in patient’s notes and on discharge documentation.
“Work is now underway to roll out a Do Not Attempt Cardiopulmonary Resuscitation training package as part of the overarching End of Life Care training programme.”
Cardiopulmonary resuscitation, attempting to restore breathing or blood flow to critically-ill patients, is often a violent process with rib fractures and brain injury significant risks.
Up until the court ruling last week, healthcare workers have acted under professional guidance from the BMA and local trust policies, but there has been an apparent lack of clarity over just how far they have to go in consulting a patient or their families.
Dr Ian Stanley, medical director at ELHT, said a new policy was introduced in April last year to ensure that resuscitation discussions always took place with patients and their families.
He added: “We have had two main areas where DNACPR has been identified as an issue. One identified some concerns that there were decisions being made which were not fully discussed; this was fairly historical and was one of the reasons for us to re-emphasise our policy and ensure that all such decisions were discussed.
“As part of the mortality review process and case note reviews there was a view that some patients should have had a discussion about DNACPR as the chances of survival if they suffered cardiac arrest were very, very low and hence CPR would be inappropriate.
“I believe that the reasons the discussions are not taking place are related to adverse media coverage, confusion about the legal aspects and overall misconceptions that DNACPR means ‘do not treat’ - again our policy and training are very clear that this is not the case, but the public perception can be very different.”
He said a draft report by the Care Quality Commission, following a major inspection last month, had found that ‘appropriate discussions had taken place and were appropriately documented’.
He added: “This is a very emotive issue and one where real sensitivity is necessary. Firstly, ‘do not resuscitate’ absolutely does not mean ‘do not treat’. But for some patients with many co-existing diseases, or those who may be terminally ill, or very frail, there may be a significant chance that resuscitation following a cardiac arrest may be unsuccessful.
“In these circumstances, many patients are quite clear that they do not wish to be resuscitated, but this is often a very difficult concept for families and loved ones.
“We do our best to handle this in the most appropriate way but it is really important that doctors have these difficult discussions with patients, and that they are clearly documented so there is no cause for doubt. Families can then be clear that the wishes of their loved one are being respected.”
Dr David Wrigley, who represents Lancashire doctors in the British Medical Association, said: "Decisions regarding cardiopulmonary resuscitation can be complex and incredibly distressing for patients and people emotionally close to them. Therefore we welcome the judgment's clarification of the law in this complex area of medicine and are committed to updating our guidance as policy and legislation develops."
Paul Foley, who represents East Lancashire nurses in the Unison union, said: “In their day-to-day work NHS staff treat patients and their families with great dignity and respect, sometimes in the most difficult and distressing circumstances. We welcome the Court of Appeal’s ruling as we believe that patients should always be involved in decisions about all aspects of their clinical care.”