The awkward questions arising from a tragic case

It was a well-meaning decision which was to have momentous consequences.

When a 78-year-old resident at The Grove care home in East Carleton suffered serious breathing difficulties on the evening of April 28 last year, staff were alerted.

But rather than administer CPR in an effort to revive him, the home's deputy manager, Jennifer Sabbagh, opted not to do so.

She also stopped colleagues from administering the procedure and from placing him from his bed onto the floor so that resuscitation could be carried out.

Jeni Sabbagh, pictured in 2014 (Image: Archant)

"We're not doing that. He's going with dignity," she said. "I won't put him on the floor. He's breathing his last."

The man, who had been living at The Grove for 10 years, did indeed die. And Ms Sabbagh, who had been a nurse for 40 years, found herself prosecuted for neglect.

This week she admitted the offence and was sentenced to 100 hours of unpaid work.

Her legal representative insisted her sole intention had been to preserve the man's dignity and to comfort him in his last moments, but added that she now accepted the decision she made was not hers to make.

The judge in the case, Alice Robinson, said there was "a significant amount of mitigation" and that Ms Sabbagh's actions were a "genuine attempt to do the right thing". Many in the nursing profession might sympathise.

It may be one of the hardest things of all to talk about, but if the case highlights one thing it's the need for carers and loved ones to be clear when it comes to the wishes of the elderly and their families, so they can act in accordance with them when the end of their life comes.

DNR (do not resuscitate) forms are a source of solace for some. Also known by other names - such as DNACPR (do not attempt CPR) or DNAR (do not attempt resuscitation) - they can bring the comfort of knowing that if an elderly person suffers heart or respiratory failure, their suffering may not be prolonged by treatment such as CPR, which may have limited chance of success.

The NHS says that few people make a full recovery even if their heart or breathing can be restarted. It estimates CPR is successful in one or two in 10 cases whose heart or breathing have stopped.

Even if a person can be resuscitated, the treatment itself may lead to further trauma and only prolong life for a few days.

Signing a DNR should mean you will not receive a treatment that may cause further suffering at the end of your life.

But it's clear that such a significant decision needs to be made by someone who has the mental capacity to do so - or someone who has been granted power of attorney through the proper process - and the opportunity to talk it through with their family and their carers or doctor.

While it may not be an easy conversation, it should conclude with everyone knowing where they stand - the elderly person themselves, and those entrusted with their care.

Some find the conversation an empowering one where, having made those around them aware of their final wishes, the person concerned draws comfort from knowing they will be carried out.

At the height of the Covid crisis, there were concerns that some elderly people were being pressured into signing, and that blanket decisions were being made about care.

Age UK said the decision should rest with the individual, and people had the right to make it for themselves.

It said it was crucial that people’s fundamental human rights are respected, adding: "It would be completely unacceptable to abandon these rights in favour of taking blanket, discriminatory decisions."

In order for people's rights to be respected, the absence of a DNR form should be taken as meaning that the person who has suffered cardiac arrest or respiratory failure does wish medics to try to resuscitate them.

The Grove care home (Image: Archant)

In the case of Ms Sabbagh, there was no DNR order in place for the resident, hence her prosecution.

The court heard that expert advice was sought which confirmed it was highly unlikely CPR would have been effective in this case.

That was clearly Ms Sabbagh's judgement too. In court, her representative said it was her "clinical assessment" that the man was "seriously unwell" and "taking his last breaths".

But without that DNR in place, she crossed the line into taking a decision that was not in her gift.

Leonard Cheshire, which runs The Grove, said her conduct was completely against the expectations of its staff, as well as professional nursing standards.

She may have thought she was doing the right thing by letting an 78-year-old man slip peacefully away, but for DNR to be an effective signpost for those engaged in end-of-life care, it must be black or white, either or.

These forms can protect staff as much as the person who has signed them.

That said, they do not always provide the final word. For a DNR decision can be made by a doctor, even if the patient does not agree with it in certain circumstances.

This could be because the doctor thinks that CPR will not help you live longer or could cause you more harm because your organs are already too damaged because of another illness, or you are approaching the end of your life.

You should be consulted and have the reasons explained to you, but the doctor's decision is final.

The NHS qualifies this by saying doctors do not have to give you treatment if they think it will not work.

So even with these orders in place, grey areas remain. And huge decisions rest on the shoulders of healthcare professionals.