1. Dr. Andrea Mulligan BL LL.B, LL.M(Harv.)
The Use of DNAR Orders
Dr. Andrea Mulligan BL
LL.B, LL.M(Harv.)

2. The Use of DNAR Orders I. CPR in Clinical Context and DNAR Notices
II. Irish Law and Guidance on DNAR Notices
III. UK Law and Guidance on DNAR Notices
IV. Tracey v Cambridge University Hospital

3. I. CPR in Clinical Context and DNAR Notices
Cardio Pulmonary Resuscitation:
Chest compressions
Electric shocks
Injected medications
Mouth-to-mouth breathing or inflation of the lungs
Success rates – Real v. Perceived
DNAR is a clinical decision

4. I. CPR in Clinical Context and DNAR Notices
Distinguishing DNAR’s from ADR’s
Futile Treatment
Terminological discussions
DNAR – Do Not Attempt Resuscitation
DNR – Do Not Resuscitate
AND – Allow Natural Death

5. II. Irish Law and Guidance on DNAR Notices
Constitutional background
The right to refuse treatment
The right to die a natural death
The right to autonomy/self-determination

6. In Re SR [2012] 1 IR 305
Boy, 1 year and 10 months old, involved in drowning accident.
Hospital seeks permission to make DNACPR decision.
Kearns P
Best interests of the child.
Intubation and ventilation not in best interests of SR.

7. In Re SR [2012] 1 IR 305 Kearns P on clinical judgment:
One final point should be mentioned and that is whether it would ever be appropriate for a court to require a medical practitioner to adopt a course of treatment which in the bona fide clinical judgment of the practitioner is not in the best interests of the patient. Although it does not arise in the instant case, I cannot conceive of any circumstance where such an order would be suitable, as this would clash with the primary duty of the medical practitioner to act in the best interests of their patient. The Hippocratic Oath emphasises the duty on doctors to do no harm to their patients, and that would be difficult to reconcile with an order of the court requiring them to treat a patient in a manner inconsistent with their own clinical judgment.

8. National Consent Policy (2013) - Part IV
When CPR is appropriate
Competent v Incompetent Patients
However, the role of those close to the individual is not to make the final decision regarding CPR, but rather to help the senior healthcare professional to make the most appropriate decision. Where CPR is judged inappropriate, it is good practice to inform those close to the patient, but there is no need to seek their ‘permission’ not to perform CPR in these circumstances. [p99]
Disagreements between doctor and patient
Communication and discussion

9. National Consent Policy (2013) - Part IV
DNAR notices and children
1. Parent(s)/legal guardian(s) and the healthcare team should work in partnership when deciding about CPR, with decisions being made on the basis of consensus.
2. Where appropriate, given the child’s level of knowledge, understanding and experience, he/she should also be involved and participate in the decision‐making partnership.
3. Therefore, children should be informed and listened to and their ascertainable views and preferences should be taken into consideration.
4. The final decision reached should be in the best interests of the child.
Documentation and Review

10. III. UK Law and Guidance on DNAR Notices
Joint Statement (2014)
British Medical Association, Resuscitation Council and Royal College of Nursing.
“Blanket” policies
Statutory basis for advance directives: Mental Capacity Act 2005

11. IV. Tracey v Cambridge University Hospital
Core issue: To what extent a competent patient must be informed that a DNAR decision has been made, even if that knowledge will cause them great distress?
Court of Appeal:
“Since a DNACPR decision is one which will potentially deprive the patient of life-saving treatment, there should be a presumption in favour of patient involvement. There need to be convincing reasons not to involve the patient.”

12. IV. Tracey v Cambridge University Hospital
Exceptional significance of the decision
Right to a second opinion
Risk of distress not sufficient to justify non-disclosure, must be actual harm
Doctor’s right to refuse clinically inappropriate treatment

13. The Use of DNAR Orders Questions or comments?
Questions and comments welcome:
Andrea Mulligan
The Law Library, Four Courts, Dublin 7. DX