DNACPR decisions: challenging and changing practice in the wake of the Tracey judgment.

The Court of Appeal judgment that Janet Tracey's human rights had been breached when a 'do not attempt cardiopulmonary resuscitation' (DNACPR) form was written about her without her knowledge has far-reaching implications for clinical practice. The 'duty to consult' extends to all patients apart from those in whom it is likely that discussion would cause 'physical or psychological harm'. The ethical basis for this judgment is strong: if a patient is unaware that a resuscitation decision has been made, he or she cannot ask questions, plan the future or ask for second opinions. Clinicians have, however, expressed concerns about the logistic implications of this judgment in terms of time and resource allocation, and the possibility that doctors will refrain from making resuscitation decisions at all, rather than risk uncomfortable discussions or litigation. Problems with DNACPR decisions predate the Tracey case, and a coordinated alternative approach is needed: patients should be given information so that they can anticipate, initiate and participate in discussions; resuscitation decisions should be considered early in treatment, in a community setting or at predictable junctures; resuscitation should not be considered in isolation but within the context of other goals of care. Models addressing these issues have been developed.