Musings Part 8: Returning to Father and Son, does that scenario say the death could not be certified if the GP attended ?

22-Jun-2011 10:06 am

Lawyers are better-placed to give 'logical' answers to these questions, because they simply read the law 'as it is written'. But clinicians 'impose their own beliefs and perspectives onto' the lae, and then write logically and legally incorrect guidance.
I asked the Dying Matters Coalition, what Grandfather would need to write on an ADRT, and also 'why do clinicians expect Grandfather to EXPLAIN his 'reasons' - the MCA does NOT require him to give reasons !'.
The initial contact, who I suspect was a nurse, passed it on to someone I suspect was a lawyer - he confused my 'general' question with a 'how would I personally do it', but this was the reply (I'm just going to find this in my e-mails, and cut and paste - I won't have time to sort out any weird 'formatting errors' that introduces):

Thanks for your question – I have taken advice on my response as this is not my area of clinical expertise. This advice is as follows:



Mr Stone appears to have a very clear grasp of the legal situation here.



My only advice would be to avoid using abbreviations in what he writes so that there can be no doubt about his intentions, and also that if it is indeed the case that he would not wish to be resuscitated whatever the cause of his cardiopulmonary arrest (ie even if it was something potentially readily reversible like an anaphylactic reaction to a drug or a disturbance in the rhythm of his heart that was potentially readily shockable, or he’d fallen in a canal and his lungs were full of water) that he should state this clearly



Eg

In the event that my heart stops beating or I stop breathing, whatever the cause of this and even if the cause is felt to be readily reversible, I do not wish cardiopulmonary resuscitation to be attempted.



He is correct that he does not need to give his reasons for this.



Unfortunately however, Health care professionals do not always have as clear an understanding of the legal and ethical issues around advance decisions to refuse treatments as Mr Stone has, and because CPR is an emergency treatment and has to be initiated immediately, it is easy to start treatment and ask questions later. Mr Stone would therefore need to make it abundantly clear that he had made such an advance decision to as many people as he felt were relevant, and the more explanatory his statement was, the less chance there would be of health care professionals at the time being able to say they were not quite sure that he meant it in these circumstances or “but if he had known……..he would not have written it”. Therefore if there was a clear reason for the decision which he felt might explain it and assure a reader that he did mean it to say exactly what it does say, he may wish to include it to maximise the likelihood that in an emergency situation it would be followed. I appreciate that this is not exactly what the MCA says, but it is perhaps a pragmatic answer.



I hope that this helps.

Regards


I also asked the RCN, recently, what the wording is to refuse CPR whatever causes a CPA, and it was suggested that one asks a lawyer - but lawyers do not attempt CPR, and Grandfather does not wish to sue a nurse or paramedic AFTER a CPR attempt (where a lawyer makes sense) he needs to know what would be properly understood by clinicians !
Also, if Grandfather discusses this with a GP, he will ask 'So, would that form of wording, get any nurse or paramedic to leave me to die, and to not attempt CPR ?' and the only HONEST answer is 'I couldn't guarantee it'. At which point, grandfather will presumably ask 'So, I can only be sure, if I tell my family to not call anyone, if they think I have stopped breathing - is that what I am supposed to do, then ?'.
By the way, this entire 'Musings' series is only intended
to 'prime its readers' by pushing them towards thinking about different questions, from a multi-perspective position - the discussion of the 'best resolution', is more complex, and can only be done after the people involved, have 'grasped the basic problems'.

22-Jun-2011 11:26 am

22-Jun-2011 11:08 am

I am willing to accept everything you say as true - but the law must have a pretty clear 'meaning', or else it is pointless. The MCA itself is pretty clear in its wording (although it leaves various things unresolved) and the Courts apply a thing called 'the literal test', which means a law is assumed to mean what its wording implies it to mean, unless such a 'straightforward interpretation' leads to an obvious paradox.
Your final sentence is I assume true, but misses the point - the question is, do clinicians accept that as a patient's relatives know the patient better than they do, and may be living with the patient, then the relatives will know and understand the patient's wishes, better than the clinicians ? Who is capable of 'getting into a patient's mind - the people who know him 'closely', or clinicians who merely treat him ?'.

23-Jun-2011 9:17 am

Yes, but my questions hinge on what are the legal requirements on the amateurs, and what makes sense from the perspective of relatives, etc.
It is precisely this 'from my perspective' thing, being applied by different people, combined with 'professional back-covering' and the overall complexity of the situation, that winds me up - because your existing guidance is wholly biased towards 'making things easier for the professionals'.
What do you think, the son should do in my Father and Son scenario ? Should he call someone, or should he allow his dad to die in peace, having been told to do that ?
This entire series, without trying to cause offence (but I'm sure some offence will be taken) is a 'primer', to try and get nurses to tell me what they think the law states, and what the 'correct benaviour is', so I can then move on to the discussion of the issues in detail !

23-Jun-2011 11:07 am

23-Jun-2011 10:15 am

I am sorry if I appear to be 'condescending'. But, there is either 'a right answer' or else the situation must be accepted as being as complicated as it actually is - something which current behaviour 'denies'. I am much more interested, in what nurses would say to the Police, should both nurses and the Police somehow become involved if the son had allowed his dad to die in peace, and then called someone.
And, in particular, the question is not 'what do individuals think is right' but rather 'what does the law say' - you can't accuse people of having 'different views', only of breaking a law !
I do, as it happens, believe that nurses have got a flawed belief set in this area, because the guidance for nurses is defective, when one starts from the Mental Capacity Act itself: in general, none of the 'clinical or secondary guidance' properly mirrors the Act, but the guidance for doctors is best, then for nurses, and the guidance for patients is very corrupted indeed ! My problem is with the guidance you are told to follow, not with nurses who (naturally) assume their guidance is probably 'correct'.