Research and Policy Officer, Philip Satherley, blogs about Do Not Resuscitate orders.

Spot checks of hospital practice by the Care Quality Commission (CQC) has found that one-third of DNAR (do not attempt resuscitation) orders are being issued without seeking the involvement of patients or relatives, reports the Telegraph.

Whilst I would not agree that this is ‘euthanasia by the backdoor’ it is of great cause for concern. Not only does it challenge fundamental assumptions of patient autonomy, but it also demonstrates that there is still a long way to go in ensuring that the proper protocols for both making, and recording, patient’s end-of-life decisions are followed.

Guidance produced in 2010 by the General Medical Council (GMC) stressed the importance of upfront treatment discussions with patients (where possible), their loved ones and their healthcare team. Interestingly, the GMC also state that if a DNAR decision has been made and there has been no discussion with the patient because they did not want to discuss it (for example they may be highly distressed at the idea of dying and don’t feel comfortable talking about it), or because the doctor considered that a discussion with the patient was not appropriate, this should be noted in the medical records. This is obviously a grey area of practice, so all actions taken need to be accounted for.

The blame for these incidences uncovered by the CQC cannot rest solely with healthcare professionals. Local systems for recording Advance Decisions (which might include a patient’s DNAR wishes as well as wider treatment preferences) differ across the country and there is currently no central system for recording them. This lack of coordination of a patient’s decisions has particular importance when they are first admitted to hospital and their end-of-life treatment preferences are (or should be) being discussed.

Essentially the CQC report highlights that respect and care for patients is sometimes lacking – whether this is the fault of individual clinicians or the systems they are working within. Our healthcare system continues to struggle with the process of dying, but there are basic fundamentals which we should be getting right and let’s not forget that most healthcare professionals are doing an excellent job in the face of increasingly challenging circumstances. ·