An end-of-life draft policy aims to ensure that patients of all ages are offered options to ensure they retain their dignity, writes PAMELA DUNCAN
IN CONTRAST to his dapper bow tie and the cheery vase of sunflowers which decorated the podium, Dr Patrick Plunkett’s opening remarks to a meeting held in Dublin last Wednesday were quite sobering:
“This is to warn you, you’re all going to die,” he opened to ever-so-slightly nervous laughter from the assembled crowd.
However, Dr Plunkett’s comments are apt in the context of the meeting’s topic. Organised by the Irish Hospice Foundation’s Forum on End of Life in Ireland, the meeting was convened to discuss the ongoing national consultation process around Do Not Attempt Resuscitation orders (DNARs).
The subject is one of a number of end-of-life issues contained in a draft national consent policy developed by the National Consent Advisory Group under the auspices of the National Quality and Patient Safety Directorate, which is under national consultation until June 28th.
It is envisaged that the policy will be used across the Irish health system, including nursing homes. Its aim is to provide guidance to health professionals as to how best to sensitively obtain a valid and genuine consent from patients in their care.
Dr Plunkett, who is a clinical professor of emergency medicine at Trinity College Dublin, clinical director, emergency directorate at St James’s Hospital and commissioner at St John Ambulance Brigade of Ireland, pointed out that while there is a societal discomfort around the discussion of DNARs, doctors had a responsibility to their patients to discuss what was in their best interests.
“The predictability of death is such that we owe it to the person that we discuss it with them,” he said. “Death is inevitable . . . it will happen to us all . . . There is an excessive medicalisation of death,” he said, adding that many people having CPR inappropriately should be allowed to die “in their own time and in comfort and in dignity”.
“I’m very much supportive of Do Not Attempt CPR or Do Not Attempt Resuscitation as a pre-planned decision of a competent patient for their own final outcome and that that be respected by their doctors and nurses,” he concluded.
Dr Deirdre Madden, a senior lecturer in law at University College Cork (UCC) and chairwoman of the National Consent Advisory Group, said that for certain patients, a “procedure less dignified and peaceful [than CPR] could hardly be devised”, adding that, in many cases involving a terminally ill patient it could actually cause discomfort and injury to the patient.
“Most patients want to die in peace, in dignity, at home if possible surrounded by friends, family and loved ones. They don’t want to die in a hospital, they don’t want to die attached to machines, they don’t want to die following this sort of procedure where their life is only going to be postponed for a very short time in that event.”
Dr Madden said that DNAR orders, as envisioned in the draft policy, referred to resuscitation and not to other aspects of care such as antibiotics or other forms of treatment.
She said it was important to identify patients who would be suitable for DNAR orders “to prevent this lack of dignity in otherwise inevitable deaths”.
Dr Madden added that, while many such patients would be elderly with cancer or a severe underlying illness, she added that this was “not an ageist policy, this is not intended to discriminate against any category of people. This is about ensuring that patients of any and every age are offered treatment appropriate to their diagnosis.”
Dr Siobhán O’Sullivan, the chief bioethics officer at the Department of Health and chairwoman of the DNAR sub-group of the National Consent Advisory Group, said the general principles of the draft policy was that of “open, honest, sensitive and ongoing communication” which, where possible, would be a co-decision making process between patients and their doctors. “It’s about sitting down and having that discussion and seeing what it is that person wants for their own treatment,” she said.
Dr O’Sullivan noted that a person’s family actually doesn’t have a legal role to play in resuscitation. However, she added that a patient may decide that they’d like to have their family included in the decision, and that therefore doctors also needed to ask that question of their patients.
She added that: “If an individual lacks capacity then the family again are not the decision-makers but where they can help provide insight into the previous wishes of the individual . . . they are probably best placed to advise and inform the decision,” she said.
Dr O’Sullivan said that, when finalised, the policy would address a lack of consistency around issues of resuscitation in Irish health and social care settings.
The meeting was organised by the Forum on End of Life in Ireland, an Irish Hospice Foundation initiative, which aims to promote public awareness around end-of-life issues. The national consultation process on consent, organised by the Health Service Executive, continues until June 28th.