Pain, suffering and death are to some extent, inevitable in human life, though Health care must always seek to eliminate unnecessary suffering and untimely death. But it is easy to recognise that prolonging the process of dying us often undesirable. The difficulty encountered by medical teams is to establish and act accordingly to a general policy free from prejudices and subjective judgments. Failure of the cardiac and respiratory functions is part of dying; CPR can theoretically be attempted on every individual prior to death. But, from settings to settings, situation differs; sometimes it is not appropriate to prevent death to occur. A decision not to attempt resuscitation applies only to CPR; it does not imply "non treatment" and overall treatment and care that are appropriate for the patient will continue to be considered and offered. It is important to underline the difference of DNAR with other withdrawals of treatment because people can be misjudged about them:
As the law stands, assisted suicide and all similar processes whereby one person hastens another's death are illegal. Doctors and nurses can ensure that the patient is receiving enough pain relief to keep him comfortable; it is illegal for them to give him more than he needs with the intention of ending his life more quickly. The British Medical Association [BMA], in conjunction with the Royal College of Nursing [RCN] and the Resuscitation Council [UK] produced a first set of guidance on decisions relating to CPR in 1999, in order to offer a frame to the medical practitioners and to identify key ethical and legal issues . Less than two years after, in March 2001, the same organisms, edited an updated new set of guidelines, quite different.
[...] these two guidelines, the Department of Health had issued a circular dealing with this same issue, demanding that all NHS Trusts have resuscitation policies in place by April 2001.[5] The main and decisive reason behind the update was the implementation of the Human Rights Act 1998 on 2 October 2000. Now decisions of the Health Services and all their staffs must respect the body of rights inherent to each person as the European Convention of Human Rights requires it. The decision-making must be transparent, so doctors must be able to justify that their procedures are always conform to the Human Rights. [...]
[...] The guidance validates here the judgment of Hughes J in Re AK in 2000 where a 19-year-old motor neurone disease sufferer was kept alive by ventilation. He could only communicate through movement of an eyelid and expressed by this means his wish that ventilation is stopped and no attempt to revive him be performed. In other easiest situations a discussion with a General Practitioner or another Health professional can also constitute a valid advance directive as long as the patient expresses a “clear and consistent refusal”. [...]
[...] J Med Ethics1997; 23: 207-212 - Susan Mayer: New UK Guidance on Resuscitation calls for open decision- making, BMJ March 2001 Lexique Consecration of the patient's autonomy BMA: British Medical Association BMJ: British Medical Journal BMLR: British Medical Law Review CPR: Cardio pulmonary resuscitation DNAR: Do Not Attempt Resuscitation DNR: Do Not Resuscitate GP: General Practitionner HL: House of Lords NHS: National Health Service RCN: Royal College of Nursing UK United Kingdom LMC Live pp3 Cancerbacup –Putting your affairs in order November 2003 British Medical Association. [...]
[...] They also advance practicalities preventing them from discussing DNAR, adding that most decisions have to be taken in emergency “when the patient is legally incompetent to decide either because of confusion or because of the severity of their illness.”[31] Another important defence highlighted is that most patients could not recall important details about resuscitation and DNAR decisions a week after the discussion.[32]According to certain medics, this would quite attenuate the importance to involve patient, if after all, any discussion could be considered pointless, because forgotten. [...]
[...] It is obvious that the Guidance published by the health organisms have left some gaps behind its implementation; some of reasonable importance like the problem concerning the junior doctors who cannot take decisions by themselves about DNAR and have to refer to their senior consultant, even in cases of emergency. Another gap of greater importance seen above is the possibility for the patient to refuse that any DNAR orders be written in his case notes. This section is certainly the most problematic of the document guiding the doctor's action. [...]
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