Responsibility for Decision-Making: Patients and their Relatives/Carers
A competent patient can:
Make an advance refusal of CPReven if CPR is deemed to be likely to be medically successful.
- They do not have to give a reason for such refusal.
Accept (consent to) CPR if it is offered as a treatment option.
- In the event of a cardio-respiratory arrest, CPR must only be offered if it is likely to be successful in achieving sustainable life for that patient.
A patient cannot:
Demand CPR if it is clinically judged that it would not be medically successful in achieving sustainable life for that patient.
- Healthcare staff cannot be obliged to carry out interventions that they judge are contraindicated/may be harmful.
- If agreement cannot be reached after sensitive and open discussion, a second opinion should be offered. Obtaining a second opinion is considered good practice but is not legally required if the multidisciplinary team is in agreement.
Where a patient lacks capacity for involvement in advance decisions and has no legally appointed proxy decision maker (welfare attorney/welfare guardian/person appointed under an intervention order with relevant powers) (see Appendix iv):
- The responsibility for deciding if CPR would be of overall benefit for the patient lies with the lead clinician for the patient.
- In order to establish this decision, it is good practice, and also a requirement, to consult with those close to the patient, as well as taking what steps are possible to establish the wishes of the patient.
- Family/carers/next of kin do not have decision-making rights or responsibilities in this circumstance. Discussion with the family has the primary aim of clarifying the patient's prior views/wishes, and what they feel the patient would have chosen in this situation. Discussion should also enable family to express their own views on what they feel would be of benefit for the patient.
Where a patient lacks capacity for involvement in advance decisions and a proxy decision maker (legally appointed welfare attorney/welfare guardian/person appointed under an intervention order with relevant powers) has been identified (see Appendix iv):
The proxy decision maker can, if they have powers in relation to medical consent;
- Accept (consent to) CPR if offered.
- Refuse to consent to CPR if offered. However, if the treating doctor believes that offering CPR would be justified, the doctor can use the procedure in section 50 of the Adults with Incapacity Act, to obtain a second opinion from a doctor nominated by the Mental Welfare Commission. This opinion is final unless appealed to the Court of Session. (Formally, this procedure applies to the actual treatment, not the granting of a DNACPR certificate. However, if the discussion about a DNACPR certificate makes clear that the guardian or attorney does not agree with the doctor's wish to treat in appropriate circumstances, this procedure may be invoked.)
The proxy decision maker cannot:
- Demand CPR if it is clear that CPR will not be successful in achieving sustainable life for the patient.
However, the proxy decision maker must be consulted about any advance decision to give or to not give CPR. If agreement about a decision not to offer CPR cannot be reached after sensitive discussion, a second opinion should be offered, although this is not a legal requirement where the multidisciplinary team is in agreement.
Email: Elizabeth Gourlay, firstname.lastname@example.org