15.4 End-of-Life Decisions, DNACPR, Organ Donation, Adult Safeguarding & Domestic Abuse
Key Takeaways
Doctors are not obliged to provide CPR that would not work, but must discuss a DNACPR decision with the patient unless this is likely to cause physical or psychological harm (Tracey, 2014).
A DNACPR decision applies only to cardiopulmonary resuscitation; all other appropriate treatment and care continue.
An advance decision refusing life-sustaining treatment is legally binding only if valid and applicable, written, signed, witnessed and states that it applies even if life is at risk.
Under the Care Act 2014, safeguarding duties apply to an adult with care and support needs who is experiencing or at risk of abuse or neglect and cannot protect themselves.
Domestic abuse should be asked about in private with a professional interpreter if needed; information can be shared without consent to prevent serious harm or protect children.
End-of-Life Decisions, DNACPR, Organ Donation, Adult Safeguarding & Domestic Abuse
Advance Care Planning
Advance care planning lets people record their wishes for future care while they have capacity. Tools include the ReSPECT process (Recommended Summary Plan for Emergency Care and Treatment), which records personalised recommendations including CPR, and conversations recorded in the shared care record. GMC guidance on treatment and care towards the end of life asks doctors to start these discussions early, involve those close to the patient where the patient agrees, and review plans as circumstances change.
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
- CPR is a treatment. Doctors are not obliged to provide CPR that is not clinically indicated (it would not work or the burdens clearly outweigh the benefits), and patients cannot demand it. Offer a second opinion if there is disagreement.
- Involve the patient: after R (Tracey) v Cambridge University Hospitals (2014), there is a legal duty to discuss a DNACPR decision with a patient who has capacity unless the discussion is likely to cause physical or psychological harm (distress alone is not enough).
- If the patient lacks capacity: consult those close to them or an attorney (Winspear, 2015), and make the decision in the patient's best interests under the Mental Capacity Act.
- A capacitous patient can refuse CPR, and that refusal must be respected.
- A DNACPR decision is about CPR only. It does not mean withholding antibiotics, fluids, oxygen, ICU review or other treatment.
- Decisions must be documented clearly, communicated to the team, and reviewed when the situation changes. A DNACPR decision based on a protected characteristic or disability alone is unlawful.
Advance Decisions & Lasting Powers of Attorney (Mental Capacity Act 2005)
| Instrument | Key Points |
|---|---|
| Advance decision to refuse treatment (ADRT) | Made by an adult with capacity; legally binding if valid and applicable to the situation. To refuse life-sustaining treatment it must be in writing, signed, witnessed, and state that it applies "even if life is at risk". It cannot demand treatment. |
| Advance statement | Records wishes and preferences; not legally binding but must be considered in best interests decisions |
| Lasting power of attorney (health and welfare) | Registered with the Office of the Public Guardian; the attorney can make decisions only when the person lacks capacity, and can refuse life-sustaining treatment only if the LPA expressly allows this |
| Court of Protection / deputies | For serious disputes or where no other lawful decision-maker exists |
Withholding & Withdrawing Treatment
There is no ethical or legal difference between withholding and withdrawing a treatment that is not in the patient's best interests. Clinically assisted nutrition and hydration is a medical treatment; decisions to withdraw it from patients who lack capacity follow best interests guidance and do not need court approval when everyone agrees (Re Y, 2018).
Euthanasia & Assisted Dying
At present, euthanasia is unlawful (it can be murder or manslaughter) and encouraging or assisting suicide is an offence under the Suicide Act 1961 in England and Wales. Parliament has been considering legislation on assisted dying for terminally ill adults, so check the current law; until any new law is in force, doctors can listen, explore the patient's fears and provide palliative care, but must not give advice or help that encourages or assists suicide. Giving drugs with the intention of relieving symptoms, even if they might shorten life, is lawful (the doctrine of double effect).
Care in the Last Days of Life (NICE NG31)
Recognise that a person may be dying, communicate with them and those close to them, consider stopping non-essential medicines and tests, and prescribe anticipatory medicines for pain (opioid), breathlessness (opioid), nausea and vomiting (for example levomepromazine), agitation (midazolam) and respiratory secretions (an antimuscarinic such as glycopyrronium). Support hydration as the person wishes.
Organ Donation
Deemed consent ("opt-out") applies to adults in England (since 2020), Wales (2015), Scotland (2021) and Northern Ireland (2023), with exclusions for under-18s, people who lacked capacity for a significant period before death, and people not ordinarily resident. The family is always consulted and can provide information about the person's wishes. The specialist nurse for organ donation should be involved early; doctors caring for the patient do not raise donation before the decision to withdraw treatment or confirm death.
Adult Safeguarding (Care Act 2014)
Duties apply to an adult who has care and support needs, is experiencing or at risk of abuse or neglect, and cannot protect themselves because of those needs.
Types of abuse: physical, sexual, psychological, financial or material, discriminatory, organisational, neglect and acts of omission, self-neglect, domestic abuse, and modern slavery.
Doctor's actions:
- Make the person safe and treat injuries; record findings accurately.
- Discuss concerns with the adult and seek consent to share, in line with Making Safeguarding Personal.
- Refer to the local authority safeguarding team (using the organisation's safeguarding lead). Information can be shared without consent if the adult lacks capacity, others (including children) are at risk, a serious crime is involved, or there is a risk to life.
Domestic Abuse
The Domestic Abuse Act 2021 defines domestic abuse as abusive behaviour between people aged 16 or over who are personally connected, including physical or sexual abuse, violent or threatening behaviour, controlling or coercive behaviour, economic abuse and psychological abuse. Children who see, hear or experience its effects are victims in their own right.
- Ask in private, without the partner present, using a professional interpreter (never a family member).
- Assess risk (for example the DASH risk checklist); refer high-risk victims to a Multi-Agency Risk Assessment Conference (MARAC) and an independent domestic violence adviser.
- Document carefully, consider children (safeguarding referral), and share information without consent when needed to prevent serious harm.
- Routine enquiry is part of antenatal care and mental health assessment because abuse often starts or escalates in pregnancy.
Prevent
Under the Counter-Terrorism and Security Act 2015, NHS staff must have due regard to preventing people being drawn into terrorism. Concerns about radicalisation of a vulnerable person are discussed with the organisation's Prevent or safeguarding lead.
Professional Use of Social Media
GMC guidance applies online as offline: maintain patient confidentiality (anonymised details can still identify people), do not give individual medical advice on public platforms, identify yourself by name if you comment as a doctor, maintain professional boundaries (do not accept friend requests from patients), and remember that posts may be permanent and public.
An 84-year-old man with metastatic lung cancer and capacity is admitted with pneumonia. The consultant believes CPR would not be successful. The patient's daughter asks that her father not be told about the DNACPR decision because he will be upset. What should the doctor do?
Record the DNACPR decision without telling the patient, as his daughter requests
Discuss the decision sensitively with the patient, as distress alone is not a reason to avoid it
Continue full resuscitation until a court decides
Ask the daughter to make the decision on his behalf
A 76-year-old woman with dementia attends with unexplained bruising on both upper arms. She lives with her son, who manages her money, and she says he "gets angry". She lacks capacity to make decisions about her safety. What is the most appropriate action?
Treat injuries, document them and refer to adult safeguarding
Arrange a routine follow-up appointment in 3 months to review
Take no action without her consent to share information
Ask her son to explain the bruises and accept his account
A man has a valid, signed and witnessed advance decision refusing mechanical ventilation, which states that it applies even if his life is at risk. He now has severe pneumonia and lacks capacity. His wife wants him to be ventilated. What should the doctors do?
Ventilate him because the advance decision was made when he was well
Apply to the Court of Protection before every treatment decision
Ventilate him because his wife is the next of kin
Respect the advance decision and not ventilate him, providing other appropriate care
Sections you finish are checked off in the contents.