COVID-19: use of DNRs (Do Not Resuscitate) & ACPs (Advance Care Plans)

Sometimes critical decisions are needed to continue, stop or start life-saving treatment. COVID-19 attacks respiratory systems and patients or family members are being asked to express wishes regarding cardiopulmonary resuscitation (CPR)

Coronavirus is affecting many people who may not have considered how they would like to be treated or cared for and if they would like to be resuscitated if they suddenly fall seriously ill.  

If you have made a decision yourself, it is sensible to let family members and carers know in advance so that it does not come as a surprise to them if the circumstances arise.  This is even more timely, since recent press coverage has brought DNR’s and Advanced Care Plans to the public’s attention, but what exactly are they?

Do not resuscitate (DNR)

DNR - sometimes also called a DNAR or DNACPR - is commonly used as evidence of a decision specifically not to resuscitate, that is to provide CPR in the event that it would become necessary.  A DNR does not affect other treatments a patient could receive. Usually they are used if someone is nearing the end of their life or has a complex medical condition. The paperwork is normally completed by medical professionals together with the patient (providing they have capacity to do so), or where the patient lacks capacity, by their family.  Once the decision is made a DNR or DNACPR order is placed on medical records on a form the health professionals will recognise.

DNR and consent

While there is a duty on medical professionals to consult with patients on any decision that will affect their private life, there is no right to demand that the doctor provides CPR if medical opinion is that it would be unsuccessful, or that the burden of CPR outweighs the benefit to the patient. CPR may restart the heart and breathing but leave the patient with a poor quality of life, therefore it is not in the patient’s best interest.  It is important to note all decisions should be made on an individual basis and there should be no blanket policies dictating the use of DNRs. 

Certain care homes and health centres have recently been criticised for contacting groups of patients in certain categories to make plans to prevent them being resuscitated. On 7 April 2020 the chief nursing officer for England and chief medical officer published a letter to all NHS trusts and other health and care providers confirming the care which must be taken when considering DNACPR orders –  a copy of which can be seen here.

DNR and capacity

It may be the case that a DNR is required for a family member who lacks capacity to make the decision for themselves. In these circumstances, a court of protection order appointing a deputy for welfare would allow the deputy to make the decision on behalf of the patient. Similarly, a registered lasting power of attorney for health and welfare may also authorise the attorney to make the decision.

If there is no authority already in place, a DNR decision can be made collectively in the patient’s best interests. Families and carers should be involved in the decision-making process and given the opportunity to understand it, explain the patient’s wishes if known, and explain their wishes.

What if there is a disagreement with the DNR?

If a doctor has made the decision to DNR, good practice dictates the decision is discussed by all involved and a second opinion obtained. If the disagreement remains,  it is important to seek legal advice in respect of involving the Court of Protection. It is important to note, the courts will not compel a doctor to give treatment that they consider not to be in the patient’s best interests.  Further, a DNR decision is often made in time-pressured situation in the final stages of a family members’ life.  Therefore, a decision to involve the courts and the time this will inevitably take must be considered carefully.

Advanced decisions

An advance decision - sometimes called advance decision to refuse treatment (ADRT), living will, or advance directive - is a decision that can be made now to refuse a specific type of treatment(s) at some point in the future. The advantage of this is that it allows health professionals and your family to have clear instructions regarding your wishes about refusing treatment. An advance decision will only be used if, in the future, you're not able to make your own decisions about your treatment. It is possible to refuse a certain treatment in some circumstances, but not others therefore it is important to explain clearly all the circumstances in which you want to refuse the treatment. 

An advanced decision is legally binding under the Mental Capacity Act 2005 (England and Wales), and healthcare professionals must follow it if it meets the following requirements:

• you must be over 18 and have mental capacity; 
• it clearly states what treatments you want to refuse;
• it clearly sets out the circumstances when this treatment should not be used (e.g.  if you have a stroke or heart attack); and
• if you want to refuse life-sustaining treatment you must also make sure:

 - the form is in writing

 - the form is signed and witnessed

 - you include a statement that says this is your choice even if your life is at risk or shortened as a result

It only applies if the treatment you have stated you do not want to receive is the treatment being considered, otherwise the treating healthcare professional will decide whether to use the treatment based on whether it is in your best interests. 
 
There is no obligation for anyone to see your advanced decision, but it is sensible that your medical professionals and your family know about it and where to find it, particularly in the case of an emergency. It is possible to have a copy of your advanced decision placed on your medical records.

Advance statement

This is a general statement about the things that are important to you when it comes to your health, care and wellbeing. This can relate to any part of your life, health or care. It does not have to be written and can be in video or audio format. An advance statement is not legally binding, so if you have set out instructions in one, the treating healthcare professional does not have to follow them, but can take them into account when making any decisions about your care or what is in your best interests.

Advance care plan (ACP)

An ACP is normally made when you are nearing the end of life.  It is different to any of the above which can be made at any time. An ACP is used to record your treatment and care wishes. It should be attached to your medical notes so that anyone who is caring for you has access to it. If you have made an advance decision, advance statement or an LPA it should be noted in your ACP.

An ACP is not legally binding, but it will help your healthcare team know what is important to you, and they can try to follow your wishes. They must take the document into account when deciding what is in your best interests. The NHS has published a COVID-19 advance care plan form with guidance to help complete it. Usually an ACP is created together with your healthcare team but if you fall ill and need urgent attention there may not be time for this. The form and guidance can be found here.

Lasting power of attorney

When considering future decision making and capacity it is sensible to consider writing a lasting power of attorney (LPA). This allows you (the donor) to give one or more people that you trust (attorneys) the legal power to make decisions on your behalf should you become unable to make decisions yourself.

There are two different types of LPA, one for property and financial affairs which covers decisions about money and property, and one for health and welfare which covers decisions affecting health and personal welfare. Only attorneys named in a health and welfare LPA will have authority to make decisions regarding your health.

Whilst LPAs are certainly useful when planning for the future, the process to enact them requires documents to be registered with the Office of the Public Guardian to bring them into effect.  Registration takes between eight to 10 weeks, therefore they should be considered at an early stage so that they are effective when required.