Woman who feared her life was 'signed away' by doctor
'Do Not Resuscitate' orders are becoming an increasing concern for patients and families, writes Alan O'Keeffe
'Do Not Resuscitate' requests relating to seriously ill patients are becoming an issue of growing importance in the lives of Irish people.
Sooner or later, many people will be faced with deciding what medical interventions they do or do not want for themselves or for loved ones no longer capable of making such an important decision.
Hospital doctors treating certain patients who may be nearing the end of their lives may choose not to carry out certain medical interventions if they feel it would not benefit those patients.
The Assisted Decision Making (Capacity) Act 2015 which comes into force towards the end of next year deals with the use of Advanced Healthcare Directives which specify people's wishes concerning their end of life care. The new law will help honour those wishes.
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But many people are still unclear about the use of orders known as ''Do Not Attempt Cardio-Pulmonary Resuscitation'' or DNACPRs.
Last month the Sunday Independent was contacted by a man who said he was very upset to discover a DNACPR order concerning his mother was signed by a doctor on the day she was brought to a hospital's emergency department. He claims his mother was not aware of the form being signed.
His 86-year-old mother has a history of heart failure and had been rushed to her local public hospital three times over a 10-week period when she had serious difficulty breathing.
On the first two occasions, an ambulance took her to hospital and she was seen to quickly and subsequently allowed to return to her home. On the third occasion, her son drove her in his car at high speed to the hospital's emergency department. She spent three weeks in the hospital until she was well enough to go home and was discharged.
At no stage did she suffer a cardiac arrest.
On the DNACPR form, her son noticed that the doctor had written that his mother's heart function showed an ''ejection fraction'' of only 10 to 15pc, figures that are far below normal, and that "chest compressions and cardiac resuscitation would be inappropriate in case of cardiac arrest."
The doctor ticked a box on the form which stated: ''This person is not for CPR as it is unlikely to be of any benefit to the person and a decision not to attempt CPR has been made.''
The doctor also ticked another box on the form which stated: ''This was discussed with the person.''
The form also contains a printed statement: ''This decision should be discussed with other relevant parties such as close family or friends with the consent of the person where appropriate.''
The son claims that the DNACPR decision was not discussed with him, his mother or any other member of the family. As part of a process of seeking a second opinion on his mother's overall condition while she remained in hospital, he was looking through his mother's medical files when he discovered the DNACPR form.
He immediately complained very strongly to the hospital management and to doctors at the hospital. He demanded that the ''do not attempt CPR'' order be reversed and this was done, he said.
He said he used very robust language when speaking to the doctor who signed the form. The man claimed the doctor told him that statistically an 86-year-old patient with heart failure would have a very poor outcome from a CPR attempt.
The man said he told the doctor he felt his mother was being placed "on the scrapheap" because of her age.
The man made an allegation that the doctor ''admitted'' to him during a conversation that he did not discuss the DNACPR decision with his mother. Despite the Sunday Independent making a number of requests, both the doctor and the hospital authorities declined to speak about the man's allegation. Neither would they comment on whether the hospital's DNACPR policy was followed in this case.
A hospital spokesperson stated that no information would be given about the patient, even though the patient had clearly stated that she wanted the hospital to release information about her case to this newspaper.
Management stated that the patient and her family had not directly complained to the hospital and they were free to do so under the HSE's dedicated complaints process ''Your Service, Your Say''.
The spokesperson also stated there were "major inaccuracies" in assertions that were made, but declined to identify what exactly those "inaccuracies" were.
Speaking to the Sunday Independent about the situation, the woman was adamant that she was not consulted about the CPR, adding that she does not have problems with her memory. She is in fact a relatively fit and outgoing pensioner who still enjoys going for long walks near her home, singing her favourite songs, and likes to meet friends in the local pub.
The woman said she was shocked to discover when she was eventually released from hospital that the order had been implemented and insisted that she would never be in favour of being the subject of a DNACPR order.
"I love life too much. If anyone made an order like that I'd come back and haunt them. I'm fine now, thanks be to God… I've a few good years left to live yet," she said.
Her son said "Her cardiologist said she is an amazing woman because of the things she can do despite her heart being so weak."
Despite the family's unhappiness with the DNACPR order, the woman was emphatic in her praise for the care she received in the hospital. "I got excellent care and all the staff at the hospital were marvellous," she said.
The hospital in question was contacted multiple times by this newspaper and gave a similar response each time. Last Thursday they responded to our queries, stating the hospital management "wish to reiterate, once again, that it would be totally inappropriate under any circumstances for them to engage with a third party regarding the clinical interaction of a patient".
"Patients who have any issue with their care are encouraged to make use of the HSE's dedicated complaints process 'Your Service, Your Say'."
Stephen McMahon, spokesperson for the Irish Patients Association, said: "We have encountered a number of families that, at times of great stress, find out that a Do Not Attempt Resuscitation order has been placed on a family member without their knowledge or consultation."
Mr McMahon said he understands there are "very valid reasons" why DNACPR decisions are made that are in the best interests of patients, including very frail patients. He called for more effective disclosure of information to patients and families.
Deirdre Shanagher, national development manager of the Irish Hospice Foundation, said doctors do not have to administer CPR to a patient if they do not deem it is appropriate.
"A family can't demand that a patient gets CPR. If the clinician believes that CPR would be futile, they can stand by that decision," she said.
When informed of the allegations of the woman's family, she said: "The problem can be communication. There should be a process of consent and a documentation of the communication with the person and whoever she wanted present for that communication."
She said she had a feeling such cases were not isolated events.
She said there is a false perception among the public that the family can make a decision on behalf of their loved one when, in fact, they cannot unless they are given legal authority to do so.
She said it is important that all people, young and old, consider making Advance Healthcare Directives which allows them to appoint a designated healthcare representative who can interpret their wishes and preferences on their behalf.
She urged people to consider filling in ''Think Ahead'' forms can be enormously helpful for patients and their families in specifying the type of end of life care they desire. These forms are available from the foundation.
A retired palliative care consultant told this newspaper recently that the general public can get a false impression about the success rates of CPR. Medical dramas and soap operas on television show high rates of success but the "real life" outcomes for success were "much lower."