Do Not Attempt Resuscitation Orders
CPR (Cardio-pulmonary resuscitation) is given to patients in cardiac and/or respiratory arrest to prolong life. CPR can encompass chest compressions, ventilation of lungs, defibrillation with electric therapy and injection of drugs. The survival rate after CPR is around 15-20% in a hospital setting.
What is a DNR order?
Also known as DNAR (Do not attempt resuscitate orders). DNRs are Do Not Resuscitate orders. This is a legal order which tells a medical team not to perform CPR on a patient. However this does not affect other medical treatments.

What is an AND?
AND stands for Allow Natural Death. Some physicians have suggested that the term DNR be replaced with AND. They argue that the abbreviation should stand for an action - "allowing" death - rather than the omission of an action - "not resuscitating" - which, they argue, elicits negative reactions. However, it is unlikely that such a prevalent term as DNR will be replaced in the near future.
What is the purpose of a DNR?
A DNR supports a patient's autonomy past the point where they are able to express this autonomy. Consequently, a DNR provides written evidence of a patient's wishes that can be used to guide the appropriate course of action taken by a medical team.
Is a DNR a form of advance directive?
Does every patient have CPR?
When patients have cardiac and/or respiratory arrest there is presumed consent to CPR unless the patient specifically refused this therapy in advance.

There will be some patients for which CPR would be inappropriate (final stages of terminal disease where CPR would not be successful). Neither patients nor relatives can demand treatment which is clinically inappropriate to them.

Can DNRs be suspended?
For some patients on DNAR orders, they may develop cardiac or respiratory arrest via reversible causes (choking, anaphylaxis etc.), and in those situations CPR would be appropriate, unless the patient has specifically refused treatment in such cases.

For patients with established DNAR orders going into procedures known to have a chance of causing cardiac/respiratory arrest (e.g. cardiac catheterisation, surgical operations), DNARs may be temporarily suspended on discussion with the patients.

Should patients always be informed about DNRs?
Individual circumstances should dictate whether the DNR should be discussed with the patient. Some patients prefer to know in detail their care plans. For some patients who are approaching the end of life, informing them about a DNR order would be of little or no value. Clinicians should document the reason why a patient has not been informed of a DNR order; as they may be asked to justify their decision. This is especially the case of patients where they have indicated a clear desire to avoid such discussions.
What happens if the patient lacks capacity?
Patients undergoing cardiac/respiratory arrest will lack capacity. However valid advance directives can be set in place for this occurrence.

Patients with capacity can refuse CPR in advance (as they can with all other treatments) without necessarily giving justification to their decisions. However the health team must ensure that their decision is not based on any inaccurate information or any misunderstanding.

If a person lacks capacity and has appointed a welfare attorney who has authority to make clinical decisions; (or via a court appointed guardian to act on the patient's behalf), they should be informed of the DNR. Any previously expressed wishes should be considered whilst making a DNR decision.

What if a patient does not have an advance directive or LPA?
If a patient has not created an advance directive or LPA, family and friends may be consulted about the DNR. However, the final decision rests with the most senior consultant in charge of the patient. Guidelines regarding patients who lack capacity are complex, and vary in different areas of the UK.
What happens if patients request CPR to be attempted?
If patients request CPR to be attempted, even if clinically there is a small chance of success the health care team should usually respect that decision. However there should be an honest discussion with the patient of the quality of life that can be expected post-CPR. If there is a lack of agreement then seeking a second opinion may be required.
Does the DNR apply to CPR only?
Yes. The DNR only applies to CPR, and does not apply to any other aspects of good routine care (biopsies, dialysis, surgery etc). All other aspects of treatment should continue.
Can children agree to DNRs?
A child (anyone under 18) can refuse to consent to medical treatment. However, this refusal can be overruled by the parents of the child or by a court. It is interesting to note that although there is right in law for patients to consent to treatment if they are below 16 (Gillick competence), or aged 16-17 (Family Law Reform Act 1969 s8), there is no right in law for patients to refuse treatment.
What does a DNR form look like?
DNR forms differ between hospitals.

An example can be found here East Midland's DNR form

Transplantation issues
Within the period of April 2009 - March 2010, over 3709 transplants was carried out, with over 7800 people still waiting on the transplant list.

What is the criteria for organ donation?
Everyone who is considered legally competent can donate. Entry into the register provides the legal consent for donation.
  • Brain stem dead and maintained on a ventilator
  • No blood borne viruses (hepatitis or HIV)
  • No history of malignancy
  • No systemic infections
What about if I can't give blood?
The criteria for organ donation are distinct from those regarding blood donation. This means that even if you can't give blood, you may still be able to donate your organs.

What can be donated?
The heart, lungs, liver, pancreas, kidneys and small bowel can all be transplanted. In addition, many tissues such as corneas, skin and bones can be donated - these are solely taken from living donors.

What is brainstem death (BSD)?
If the brain stem is damaged, the centres that control breathing and circulation fail and the patient could die. This is the point at which mechanical life support should be discontinued and retrieval of organs for transplant considered. A decision might be made as to the whether the corpse should be maintained on the ventilator until the organs may be harvested.

BSD is diagnosed by 2 doctors (registered for at least 2 years, competent in their field, not members of the transplant team, at least 1 is a consultant) on two different occasions.

Legal time of death = when first test indicate BSD
Death is pronounced at the second set of tests

What is the clinical diagnosis for brainstem death (BSD)?
  • Absent brain stem reflexes (pupillary, corneal, vestibulo-ocular, oculocephalic)
  • Absent motor reflexes
  • Apnoea with pCO2 > 6.65kPa (patient does not try to breath once ventilator has been disconnected)

What is the patient has a donor card but the relative refuse donation?
If the patient carries a signed donor card (or on the NHS Organ Donation Register), under the Human Tissue Act 2008 there is no legal requirement to ensure that the relatives do not object (even if the donor was a child).

The relatives views should be taken into grave consideration, and if they are opposed to the process then it may be wise to put their wishes first.

Can the donor impose conditions on the use of the organs?
No. Neither the donor nor relatives can impose any conditions on the use of the organs.

Can the relatives of a donor refuse donation?
If the patient is a registered donor, relatives do not have a legal right to overrule their wishes. Consequently, they will discuss the matter sensitively with the medical staff, and encouraged to accept the donor's wishes.

What if the patient's wishes are unknown?
If the wishes of the patient are not known, then under the Human Tissue Act the person who owns the body can authorize the removal of organs. This is usually the next of kin or the executor of the will.

Authorization can be given only after it is clearly established that:

  • The deceased has no objections to being used as an organ donor
  • The relatives do not object
  • There are no religious considerations

Can a living donor be forced into giving an organ?
Say in the case of a patient who requires a kidney from his twin to survive. There is nothing the doctor (or the court of law) can do to force a person to donate an organ/tissue if they clearly do not choose to do so, even if the recipient will die without the transplant. The Human Tissue Act 2004 specifically requires actual consent in all cases.

Can payment be made for an organ?
No. Under the Human Organ Transplants Act 2004 (This Act superseded the Human Organ Transplants Act 1989), it is a criminal offence to make or receive payment for supplying an organ from a living or dead person.

However payment does not include reasonable expenses (costs of removing, transporting, loss of earnings) paid to a living donor.

Suicide, Assisted Suicide, and Euthanasia
The commonest definitions of terms and examples (in italics) are presented here. Note that there is intense debate in the terms used in euthanasia and there are currently no consensus definitions. However, an attempt has been made here to present the most widely adopted definitions:

Key Legal Facts Regarding Euthanasia, Suicide and Assisted Suicide:

  • Euthanasia is unlawful in England. In fact the law treats it as murder as "mercy killing" cannot be used as a defence.
  • The law does not stop people from committing suicide, in fact the Suicide Act 1961 decriminalized suicide and attempted suicide. However, this does not extend to giving "claim right" to commit suicide (i.e. expect others to provide). As a result, this decriminalization should be interpreted as "liberty right", people cannot be stopped from committing suicide but one cannot demand a suicide.
  • Assisted suicide in the forms of aid, abet, counsel or procure suicide is a criminal offence under the Suicide Act 1961.
  • Although assisted suicide is unlawful, in reality "mercy killing" (treated as assisted suicide in law) is rarely prosecuted by the Crown Prosecution Service unless it is for public interest. Between 1982 to 1991, only 24 such cases were brought to court and 3 went to prison.
  • The Director of Public Prosecutions produced a list of public factors that will be taken into account in a case of assisted suicide. Important factors in favour of prosecution are victim of age under 18, victim with mental illness or learning disability, victim does not have informed wish to commit suicide, victim did not have terminal illness and victim is able to commit suicide by himself.

Doctrine of double effect

The "Doctrine of double effect" which differentiates between the actions of the healthcare professional where death is either foreseen or intended. A healthcare professional who gives a large dose of morphine knows that the patient may die through respiratory depression but this is justifiable as it is intended for pain relief. Doctors in the UK, can prescribe unlimited amounts of pain relief so long as this is in the best interests of the patient, even if the patient's life is shortened as a result.

Contrast that with the injection of potassium chloride, where the only intention is to cause the death of the patient as there is no therapeutic value. This is legally murder.

Human Rights Act 1998
It is an important Act in the domain of end of life issues particularly in euthanasia, mercy killing and assisted suicide as numerous cases have argued that articles in this Act make euthanasia lawful. Here we present the selected articles, relevant cases and its interpretation by the European Court of Human Rights. The two landmark cases are Pretty v DPP (Director of Public Prosecutions and Secretary of State for the Home Department [2002] and Purdy v DPP (Director of Public Prosecutions) and Secretary of State for the Home Department [2009]

Article 2 - the right to life [R(Pretty) v DPP]

Pretty argued that the right life extend to a right to control the manner of one's death and therefore a right to commit suicide. The House of Lords and European Court of Human Rights held that this article imposed a duty on the state to protect life, but not a right to die.

Article 3 - the right not to suffer torture or inhuman and degrading treatment

Pretty argued that not allowing her husband to perform assisted suicide is an inhuman treatment. The ECHR held that even if the condition that she is suffering is inhuman, it is not the result of treatment by the state or inflicted by the state.

Article 8 - the right to respect for private and family life

Interpretation of this article in R(Purdy) v DPP by the House of Lords led to the DPP to produce a list of public factors that will be taken into account in a case of assisted suicide as mentioned above.

Article 9 - The right to freedom of thought, conscience and religion

Pretty argued that she was being prevented from exercising her belief that it would be best if she ends her life. However, this was rejected on the basis that there was no interference with her believes. The state can prohibit actions motivated by a person's believes.

Palliative Care
The GMC recommends that high quality palliative care should be offered to patients towards the end of their lives. Palliative care as defined by the World Health Organization is the "active, total care of patients whose disease is not responsive to curative treatment. Control of pain, other symptoms nad psychological, social and spiritual problems is paramount."

Opponents of euthanasia often use palliative care as the reason for opposing euthanasia. However, this viewpoint may compromise patient autonomy as patients are denied the choice of deciding how they should die.

The Doctrine of Double Effect distinguishes intention from foresight. Palliative care practitioners often used unlicensed high dose of analgesics to control symptoms. Administration of high dose analgesics with intention to relieve pain but may shorten the patient's life is considered lawful. However, it is not lawful if the administration of high dose analgesics has the intention to shorten the patient's life to relieve pain (i.e. euthanasia). This "doctrine" is subject to intense debate as many consider this as playing with words. However, this principle has been used in ruling of many high profile cases by Judges hence it is unlikely to be changed in any time soon.

Diagnosis of death and legal documentation

Diagnosis of Death

The ethical and philosophical debates of the definition of death have troubled many great minds in history. What are the essential elements that constitute life? Does a person with a beating heart but has no awareness and response constitute life?

One would hope that on a pragmatic level the Law would provide a simpler answer. However the legal definition of death is surprisingly unclear. The current mainstream legal definition in England base on case law is brainstem death. It is clear from Re A that a patient who was on a ventilator and certified as brain stem dead was also legally dead, this conclusion was made according to expert medical opinion. It is also clear that persistent vegetative state (PVS) is not brainsteam dead and therefore patient is legally alive in Airedale NHS Trust v Bland [1993]. Expert medical opinion therefore has a great weight when judges consider the legal definition of death. Refer to the Department of Health's "A Code of Practice for the Diagnosis of Brain Stem Death" for practical steps in diagnosing brainstem death.

Legal Documents After Death

After the diagnosis of death, the most important legal document is the Medical Certificate of Cause of Death (MCCD), which is often known as "death certificate" used for any death occurring after the first 28 days of life. Any death of a live-born infant occurring within the first 28 days of life requires a different certificate known as the Neonatal Death Certificate. Any infant born with no signs of life after 24th week of pregnancy requires the Certificate of Still-birth. Refer to the "notes for doctors" for detailed guidance in the Medical Certificate of Cause of Death book.

The MCCD must not be confused with the process of cremation which is only applicable when the body is to be cremated. The application and process of cremation is governed by the Ministry of Justice Cremation Regulation 2008, refer to their Guidance for Doctors for detailed guidance in filling in the relevant forms. There is usually a payment to the doctors for filling in the cremation forms by the deceased family members, this practice has been challenged.

  • A joint statement from the BMA, the Resuscitation Council (UK) and the Royal College of Nursing
  • Cardiopulmonary resuscitation: Standards for clinical practise and training (RCAnaesthetists, RCP, ICS, the Resuscitation Council UK)
  • Identification of potential donors of organs for transplantation: HSG (94)41 NHS Executive
  •, Human Organ Transplants Act 2004