Resuscitation orders: an overview of issues in New Zealand
The Specialist: Issue 89 - December 2011
Dr Garry Clearwater, Medical Adviser at the Medical Protection Society (MPS) looks at current issues in New Zealand relating to Resuscitation Orders.
Resuscitation Orders are known by various names (such as “Do Not Resuscitate” – DNR – directives). They are prepared in advance to assist health professionals who must make urgent decisions about an unconscious patient with cardio-respiratory collapse. Is it appropriate to start resuscitation? If so, how far should they pursue the effort with resuscitation technology?
A resuscitation decision must balance three imperatives:
- The default legal and ethical position, that health practitioners should provide emergency treatment and that witholding such treatment could be illegal if it leads to a patient’s death.
- It is appropriate to withhold treatment if it is deemed to be futile or otherwise “not in the patient’s best interests.”
- The obligation to act within the constraints of patient consent. A well-informed competent patient has the right to refuse (in advance) consent for resuscitation. It could be illegal to act against such a directive.
A Resuscitation Order should be readily available to staff at the scene of a collapse in time to effect a decision. Clinicians at the scene need to be confident that the Resuscitation Order was made by a valid process and that the order is relevant to the situation that faces them.
There is no proscribed format. The decision-making process must be robust and defensible. It can be a positive clinical exercise, requiring professional judgment and skill. Elements include:
- A sensitive discussion with key parties in a non-threatening environment and with adequate time.
- A careful evaluation of the patient’s mental and physical condition and prognosis.
- If the patient is competent, a thorough discussion to explain the issues, evaluate the patient’s wishes and to be sure that the patient is fully informed and that their consent is valid.
- Carefully documenting the discussions, rationale and decision.
- Communicating decisions in a clear and fair manner to the patient, their representatives and clinicians.
- There is an option to specify one or more specific interventions, such as basic CPR, limited attempts at defibrillation, assisted ventilation, and/or intubation.
- A Resuscitation Order needs to be routinely reviewed and updated to incorporate changes in a patient’s condition or views.
Challenges arise when the patient is not legally competent because of cognitive impairment. The wishes and philosophy of the patient may be determined from the patient’s agent (if there is one), family and staff. Points to note include:
- An advance directive, made by the patient when fully competent and adequately informed, is a very relevant indicator of the patient’s views.
- Welfare Guardians or individuals who have been granted an Enduring Power of Attorney (EPOA) for personal care and welfare matters under the Protection of Personal and Property Rights Act 1988 are excluded - in section 18(1) - from being able to refuse life-saving measures for the person in their care. For example, they cannot sign a “Do not resuscitate” order on behalf of the patient. However, their knowledge of the patient’s prior preferences could still be very influential in a resuscitation decision.
Resuscitation Orders carry risks:
- Validity (and defensibility) is compromised if they are undertaken hastily, under duress, or with inadequate consultation. This is a concern in busy acute hospital services, for example.
- They may be misused beyond their scope – at worst, for inappropriate withholding of basic humane care (such as pain relief, comfort cares) in situations apart from emergency collapse.
- Patients and/or their family may complain if they are not kept informed about, or disagree with, the decisions made in a Resuscitation Order.
As with so many other aspects of clinical practice, Resuscitation Orders require thorough discussion, clear documentation and good communication. There is always the option to consult more widely with colleagues and medico-legal advisers. The references below are recommended for a fuller discussion of the issues.
References:
McLennan S, Paterson R, Skegg PDG, Aickin R. The use of CPR in New Zealand: is it always lawful? NZMJ 2011; 124 (1328): 106-112
MCNZ statement “A doctor’s duty to help in a medical emergency (2006).”
Paterson R. New Zealand Resuscitation Council Consultation Meeting, 2009. HDC website: http://www.hdc.org.nz/media/102514/nz%20resuscitation%20council%20consultation%20meeting.pdf
Stent R (Health & Disability Commissioner). Advance Directives, Living Wills and Questions of Competence. Presentation to the NZ Hospitals Association Conference. 1997. HDC website: http://www.hdc.org.nz/education/presentations/advance-directives,-living-wills-and-questions-of-competence
Skegg PDG. Justifications for treatment without consent. Chapter 8 in Skegg PDG, Paterson R (eds), Medical law in New Zealand, 2006 Brookers, Wellington.
