Who decides to reverse a DNR? Is it next of kin or Doctor

[luckimum]

Sorry If this is in the wrong topic but I really need some advice ASAP and ill explain why.

My brother who is 38 has been in hospital for 6 weeks now with liver failure. Although the nurses kept telling us that his progress was slow we assumed he was on the road to recovery until 2 weeks ago when the consultant (who we had requested a meeting with the next day) suddenly rang my brothers wife around 8pm to tell her that my brother had 48 hours to live and asked her if she wanted to come and sit with him.

To say we were in shock is an understatement, we didnt think about the circumstances at the time, nor the fact the consultant told us my brother had been told he was facing death whilst he was on his own and no family there.
We simply raced to the hospital to be with him, and for the next 3 days we sat with him, they had withdrawn treatment and basically told us he was going to die. When he was still getting up to use the toilet 3 days later and was seeming more "with it" we did voice concerns but the doctors claimed it wasn't unusual and they it was just a matter of time. My family then held a meeting with the consultant who claimed that my brothers liver had failed and he had a minute chance of survival and even If he did, he would need a liver transplant. With this in mind, and having faith in this medical professional, when my family were asked If they would agree to a Do Not Resuscitate agreement they said they all agreed as it would not be beneficial to bring him back when his chances were so low.

However 2 weeks on, he has made a remarkable recovery up to now, so much so the doctors are treating him again, his blood levels are improving, the jaundice is lifting and he is making slow but steady progress, he has amazed us all. He is walking about and is slowly realising what has been happening. Now he claims at no point did he sign any form (which the consultant said he had) he is adamant that they never told him he had 48 hours to live and even so he should never have been told that news on his own.

Because he has made such progress and admittedly we are very concerned about the conflicting reports from different medics in this hospital, my sister in law has requested he has the DNR removed, she has explained that the circumstances are a lot different now and as he is improving and the doctors are treating him again, they do not want a DNR hanging over him now. But they seem to be fobbing her off. The nurse said she would need to speak to a doctor, she rang the doctor and was told they would ring back, by half past 5 they had all gone home and she was still waiting for a call. She has gone into the hospital this evening and they have again told her that she needs to wait till tomorrow to talk to a consultant. The consultant that was initially treating him is on holiday till 5th April so she is being fobbed off with "come and see a doctor tomorrow".

I am going into the hospital with her in the morning but can anyone tell me If the hospital are correct in stopping her from having the DNR removed? I was under the impression that it was the patients and families decision, unless the patient was terminal in which case there would be no quality of life If resuscitated. Can someone please advice?

[cdtaylornats]

Surely its up to your brother, if he is competent.

[mamadoc]

It is the Drs decision.

Resuscitation is a treatment and a dr can't be made to offer a treatment they don't think will benefit the patient.

It is best practice to discuss DNAR with the patient and/ or their family but the ultimate decision is the Drs.

Bear in mind that DNAR just means that if his heart stopped (ie he had died) they would not try to shock him back to life. The chances of resus working in real life are very small at the best of times and even less in someone with a serious illness like liver failure. If they do survive the person may have brain damage. It may still be the right decision for him to be DNAR.

BUT all treatment short of resus is still possible. DNAR does not mean you can only have palliative care or that Drs won't try hard to save your life. Maybe that is what you need reassurance on rather than DNAR per se?

[Princessdebthe1st]

Dear OP,
I am sorry you are going through such a difficult time. The answer to your question about who can cancel the DNAR order is both straightforward and complicated. The short answer is the consultant or whoever is covering for him while he is away. Resuscitation is a treatment like any other and it is in the "gift" if you like of the Dr's to prescribe it. If it is highly unlikely or definitely or will not work then it won't be done. It becomes more complicated when decisions are made on the basis of quality of life as that is very subjective. In your shoes I would start by asking the Dr to explain the reasons the DNAR order was first made and how/if his improving condition changes that decision. If you are still not happy I would ask for a second opinion from another senior consultant. The other thing that is important to realise is that just because your brother is improving does not necessarily mean that resuscitation will be any more successful if his heart stops. Good luck x

[originalusernamefail]

^^
This.

As mamadoc says the decision to reverse the DNR lies with the doctors. It would be good practice to offer you a rationale / reassurance though. For what it's worth my DMIL is in her early 50s and has had a DNR in place for the last 15 years. She has a debilitating illness (life limiting but not yet need stage / terminal) and took the decision she wouldn't want the trauma of a resuscitation attempt that would (a) most likely not work (b) leave her in a worse state than she was currently.

All other treatments are still available to your brother, including Intensive care and transplant. DNR doesn't mean do nothing.

[mamadoc]

Your brother might have signed the form or had a discussion but can't remember it now. That would not be surprising if he was very unwell.

It would be a consultant level decision to put in place or take away a DNAR nurses and junior Drs can't do it so they were correct to ask her to see the consultant in the morning and not necessarily just being obstructive.

It seems like you have all lost some trust in the medical team. Medicine is not an exact science and
dying is very hard to predict. I expect that what the Drs told you was in good faith at the time and they may be as surprised by his recovery as you are. I realise it's a painful time and very confusing to be told one thing and then another but it may be due to a rapidly changing situation. All the Drs I know are very motivated to save lives especially of younger people and if they have a failing it's usually trying too hard more than giving up easily.

Let the consultant know how you are feeling (there will be a covering one if the original one is on holiday) and I hope they'll be able to reassure you.

[garibaldi88]

Luckimum, I'm sorry you and your family are going through this. I just wanted to say that I'm not a doctor, but I've investigated a lot of complaints about DNR and end of life care. The advice you've received above is spot on. DNR does not mean your brother cannot receive full treatment to help him recover, and it seems like he really had an unexpected turn around. That is great news, and hopefully it will continue. Resuscitation after the heart has stopped is a different matter, most relatively fit people don't recover even in hospital. It is worth your sister in law discussing with doctors.

[Wolpertinger]

What mamadoc says is correct. The patient does not sign a form so your brother would not remember doing so. Also the chances of successful CPR in liver failure are unbelievably remote - CPR is really only successful in adults in trauma or heart disease. So it may still be appropriate for him to have the DNACPR even though he is clearly having very active treatment otherwise.

Doctors cannot be made to offer a treatment they do not believe would be useful but you, or rather your brother now he is well enough to have the conversation himself, has the right to have an open and frank discussion about this.