Tracey: some more thoughts

Tracey: some more thoughts

There has been a lot of interest, naturally, in the Tracey decision. Some of the comments have been insightful and thought-provoking. Some of them have been neither.

One doctor expressed his concerns about the decision with this sketch:

"Dr Ethic “Now there is something else I have to talk with you about. The High Court and General Medical Council says I must have this conversation with you. It is about cardio-pulmonary resuscitation and do not attempt CPR decisions. Now CPR is a treatment for ventricular fibrillation or ventricular tachycardia or standstill in patients who are having a heart attack. Let me reassure you that you are not having a heart attack. Now CPR is invasive causing in an elderly post menopausal woman like you, multiple painful fractured ribs and sternum. Also CPR does not work in people over 80, only in really exceptional circumstances, and certainly not on a general ward. A failed CPR results in death.

Now a recent study from Scotland shows that at your age and having been in hospital once, you have a one in three chance of death in the next year. I have to discuss with you that CPR is not going to be used when you come to die. In the meantime as I said we are going to do all the treatments that are wise and likely to work. So I am going to sign your DNACPR form and Fergus will see you tomorrow.

That’s OK then? Everyone happy, let’s move on, we have 23 more cases to see before patients’ protected lunch time, the lung MDM and my two week cancer wait clinic at 1pm, which is overbooked by 50%.”

(excerpt but full sketch available at link below)

https://www.dropbox.com/s/ptm8wtyiazgm40t/The%20DNACPR%20Sketch.doc

Obviously this is a parody (although though some po-faced and credulous journalists and nurses didn't realise this), but it illustrates an important point. The courts intervene in the doctor-patient relationship at their peril. 

One naive healthcare journalist commented that the issue was simple, it was about having compassion and respect. Thus speaks someone who has no idea about the realities of medical practice. For many frail people near the end of life, forcing a conversation on them about an intervention which would be futile is not remotely compassionate. One healthcare lawyer argued that Tracey does not entail forcing such discussions on patients. That is very much arguable. It must remembered that Mrs Tracey herself avoided the discussion of CPR.

The court ruling does not (and would not) force doctors to provide inappropriate care. So nothing about this ruling will prevent the decision being made after cardiac arrest by a junior doctor (possibly only after some undignified and painful CPR). Neither will it prevent the use of code words that signify the inappropriateness of CPR. We may just see the return of the bad old days of very few people being designated as DNAR, and having to undergo an undignified rite of passage which amounts to an assault prior to death. It would be much better to have a consistent doctrine for this invasive procedure, namely requiring informed consent for it to be provided. Why should CPR be considered as the default position for all patients of all ages in all states of health?