Do not resuscitate: final word is with medical staff, whatever patient feels
The case of Janet Tracey who died in Addenbrooke's hospital after family claims that a "do not resuscitate" order was put in her medical notes will, no doubt, encourage health managers to check how well staff and patients are acquainted with the use of such orders.
They have been given official notice to do so before. In 2000, the Department of Health in England reminded local trusts they must have appropriate policies. This followed warnings from doctors that junior staff lacked proper guidance and training and from the charity Age Concern that older people were being written off.
These warnings came after Jill Baker, 67, from Southampton, who had stomach cancer and was being treated for septicaemia, discovered after leaving hospital that a "do not resuscitate" order had been written in her notes by a junior doctor. Neither she nor her husband had been consulted.
Cardiopulmonary resuscitation (CPR) attempts to restore breathing or blood flow to those whose heart has stopped beating or who have stopped breathing. It can include using electric shocks to try to correct the rhythm of the heart, repeatedly pushing down firmly on the patient's chest and inflating the lungs with a mask or tube inserted into the windpipe.
But while TV medical dramas may suggest it is often successful, statistics tell another story.
Only 15-20% who have such treatment ever go home, according to the British Medical Association (BMA), which, together with the Royal College of Nursing (RCN) and Resuscitation Council, offers professional guidance on when Do not attempt Cardiopulmonary Resuscitation (DNACPR) orders – to give them their full name – should be prepared.
Rib fractures and brain injury are significant risks, says the NHS's policy guidance in Scotland while its leaflet for patients, relatives and carers says: "Most patients never get back the physical or mental health they had before they were resuscitated. Some have brain damage or go into a coma."
In an era when nearly seven in 10 people die in hospital – and most have "do not resuscitate" orders – there is increasing pressure for more mentally competent adult patients to help plan towards the end of their lives.
Adults can legally refuse medical treatment, even if that leads to their death. But the medical profession is also clear that doctors cannot be required to give treatment against their clinical judgment, although they should offer patients the chance of a second opinion, if possible.
The General Medical Council (GMC), last year said there was no absolute obligation to prolong life.
In 2005, it won a case on appeal brought by Leslie Burke who had a degenerative brain condition. He had claimed a legal right to artificial nutrition and hydration, come what may, rather than give doctors the ultimate say.
The GMC said the ruling meant that doctors had no legal or ethical obligation to agree to a patient's request if they consider the treatment was not in the patient's best interests.
The Scottish government is blunt on the issue. Its patient information leaflet says that while the healthcare team "must listen to your opinions and to anybody you want involved … you cannot demand treatment that will not work".
In England, where successive governments have trumpeted a mantra of patient choice, Andrew Lansley, the health secretary, has stopped short of a national policy.
The Department of Health told the Guardian: "Our end of life care strategy commended the joint statement by the BMA, RCN and the Resuscitation Council as a basis for local policy-making.
"There is a substantial amount of expert guidance available to assist those making complex decisions in discussion with other members of the healthcare team, the patient and their family."
Yet a number of soon-to-be abolished strategic health authorities in England want to harmonise policies across local care settings, including hospitals, hospices and residential homes.
In the words of Mike Richards, the government's end-of-life czar, this "will minimise future problems with cross-boundary working by encouraging a consistent – or at least compatible – approach nationwide".
A draft East Midlands document, for instance, says that there should be sensitive discussion with patients who want to insist on resuscitation in an attempt "to secure their understanding and acceptance of the DNACPR decision".
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