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An F1 doctor contacted the MDU's advice line to discuss the case of an 84-year old patient who had been admitted the previous day with severe left ventricular failure following a myocardial infarction. A do not attempt resuscitation order (DNAR) had been made after consultation with the on-call consultant.
Sometime later, the F1 doctor had received a call from a senior nurse on the ward. The patient's niece had called, very concerned that the DNAR order had been made. She said that she held Lasting Power of Attorney for the patient and was going to make a complaint. She asked to meet the consultant in charge of the patient's care. The F1 doctor had contacted his consultant, who replied that she was too busy to deal with the problem.
She said that she held Lasting Power of Attorney for the patient and was going to make a complaint.
The MDU adviser explained that the Mental Capacity Act 2005 introduced a Lasting Powers of Attorney (LPA) for personal welfare decisions, including healthcare. A personal welfare LPA allows a patient to nominate someone to make decisions on their behalf should they lose capacity. This may include decisions about end of life care and resuscitation, but this must be stated explicitly within the LPA. However, neither a patient nor the attorney can insist on a course of action or treatment that the doctors considered not to be in the patient's best interests.
Our adviser suggested that the F1 doctor arrange to meet the niece to explain her aunt's diagnosis and prognosis. The doctor should find out the nature of the Power of Attorney held. In our adviser's experience, the majority of Powers of Attorney relate to property and finance, and it is still relatively unusual to find patients who have drawn up LPAs for welfare decisions.
The GMC's guidance Treatment and Care Towards the End of Life (2010) addresses the issue of legal proxies who request that resuscitation be undertaken, even when the chances of success are small. The GMC encourages doctors to explore the reasons for the request, but emphasises that if the doctor believes that attempting CPR would not be of overall benefit for the patient, then they are not obliged to offer to attempt it. The reason for this should be explained and the option of obtaining a second opinion discussed. The doctor was advised to make detailed notes of the discussion.
The adviser also discussed the level of support that the F1 doctor had received from his consultant. He was encouraged to consider whether the consultant's behaviour amounted to a pattern which could lead to junior doctors feeling unsupported, and also impact on patient care. Alternatively, she may have been genuinely unable, through work commitments, to assist with the problem at that time.
The F1 doctor contacted us again following a discussion with the patient's niece. The niece held an LPA for property and financial affairs only. The F1 doctor explained the patient's prognosis, and the likelihood that CPR would be unsuccessful and distressing for her. It had been a difficult discussion, but all parties reached the consensus that a DNAR order was appropriate. The patient died peacefully later that day, with her niece at her side. The doctor also contacted his consultant, who apologised for not being able to assist him earlier in the day. Therefore, the doctor decided not to progress this further.
This article originally appeared in the printed edition of wardround April 2014 entitled "Difference of opinion".
This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.
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