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Tracey judgement and hospice DNACPR orders: steady as she goes or seismic change?
  1. Michael Macfarlane1,
  2. Stephanie Shayler2,
  3. Louisa Nelms1 and
  4. Derek Willis3
  5. WM CARES Group
    1. 1 Palliative Medicine, West Midlands Deanery, Wolverhampton, UK
    2. 2 Palliative Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
    3. 3 Palliative Medicine, Severn Hospice, Telford, UK
    1. Correspondence to Dr Michael Macfarlane, West Midlands Deanery, Wolverhampton, UK; mike.macfarlane{at}


    Objectives The 2014 Court of Appeals decision with respect to Tracey vs Cambridge University Hospital (‘the Tracey judgement’) changed the requirements for discussing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions with patients. This study is a retrospective case note review aiming to identify any changes in practice around discussing DNACPR decisions in hospices following the judgement.

    Methods 150 case notes from 2013 (before the Tracey judgement) were compared with 150 case notes from 2015 (following the Tracey judgement). These notes came from five hospices in the West Midlands. The notes were analysed to determine if the judgement resulted in changes to how frequently DNACPR decisions were discussed with patients and their families, as well as whether there were any changes in the documentation of reasons for not discussing such decisions.

    Results Discussions with patients around DNACPR decisions increased from 31% to 60% and with relatives from 29% to 59% following the Tracey judgement. Prior to the judgement the most frequently documented reason for not discussing was to avoid distress (23%), whereas after judgement it was patients lacking capacity to engage in such a discussion (40%). There was a lack of consistency and clarity in defining the concept of ‘physical or psychological harm’.

    Conclusions Although DNACPR decisions are being discussed more frequently with patients and families following the Tracey judgement, clarity on what constitutes ‘physical or psychological harm’ caused by these discussions is still required. Future research must examine whether the judgement is delaying or preventing DNACPR decisions being made.

    • clinical decisions
    • communication
    • education and training
    • end-of-life care (ethics)
    • hospice care

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    • Contributors The study was conceived, planned, supervised and written by MM, DW and SS. Data analysis was conducted by MM and LN. Data were collected by HK, CH, SR and RW. The paper was submitted by MM. All contributors are members of the WM CARES research collaborative.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Not required.

    • Ethics approval The Royal Wolverhampton NHS Trust.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement There are no additional unpublished data.

    • Collaborators Heena Khiroya, Caroline Hart, Sophie Rayner, Rebecca Watson