Doctors discussing Do Not Resuscitate in front of the patient concerned?

[xtinak]

Would it be normal for a doctor to tell a patient, or tell their family in front of the patient, that they would be a DNR? This happened today with some family members who were quite taken aback. The elderly patient herself obviously found this upsetting. Is this normal? I suppose the patient has a right to know but it seems a bit tactless and unnecessary? Not sure whether or not to be annoyed.

DNR is something the patient has chosen to apply for and be granted. Doctors do not decide for them

A DNR has to be applied for as far as I know. I dont think Drs can just decide not to resuscitate. It my be they think it would be unlikely to work but as far as I am aware they have to at least try unless there is a DNR in place.

Absolutely. The patient should be the one to make the decision if they are of sound mind.

It's not something to be applied for. It's something that should be discussed between the patient, drs involved and the wider family if necessary.

The situation doesn't sound wrong, but it does sound insensitive and badly handled. I would say that very often the family finds discussions like this harder to bear than the patient involved.
Hope you're ok OP, these things are always difficult

We had to make the decision for our mum. She didn't have capacity. It was kept in the front of her care plan. Don't think a doctor can just decide it.

It is a conversation that a Dr will initiate with a patient if they are concerned that resus would be futile. A patient can also request a DNAR themselves. It would always be discussed directly with the patient if they had capacity to understand. If they lacked capacity to understand the decision would be made in their best interest, usually with whatever family member had POA for health and wellbeing. A doctor can sign a DNAR without patients consent of medically it has been decided that any intervention would be pointless.

DNACPR can be a patient decision in the form of an ADRT but is often discussed by a clinician when the persons condition is such that CPR would be very unlikely to be successful and would be traumatic, as any cpr attempt is very invasive and most often followed by intensive care. The guidance and case law state that clinicians must involve the patient ( and family if person consents) in this discussion unless specific circumstances. Ultimately, yes, the Dr should discuss resuscitation in the event of heart stopping with the patient and their family. The crux is that this must be done in a sensitive manner and explaining that this is solely about cpr and does not stop the person receiving any other treatment, eg antibiotics, iv fluids etc. It is sometimes called “allow a natural death”.
I’m sorry your family have found this upsetting, there is a patient leaflet that can help explain this further.

Thanks everyone. Ok, that's interesting. As far as I can understand, the patient, who is of sound mind, hasn't really consented or necessarily had the opportunity to understand why a DNR was being suggested as appropriate in her case (though I think it's because it would be expected to be ineffective/cause more injury than recoverable). However, the consultant has signed the DNR. This doesn't seem quite right?

My dad's consultant told him in front of us (me, my dm, my dh and my at the time just 3 year old ds) that if anything happened to him they wouldn't attempt a resuscitation. It was the first he had heard about it and I think it hit him hard. With hindsight, he was far too weak and I think trying would have just been awful for all concerned but it definitely upset him. I think it made him realise that he'd never see my 2nd child (I was six months pregnant at the time) and he died a few days later.

I thought the patient decided if they wanted a DNR. What had the doctor signed?

My friend and her family found out her cancer had spread and was now terminal when the consultant stopped them in the corridor and said "so we're signing the DNR right?"

Absolutely. Of course.

I work in acute elderly medicine. The thought that a DNAR should be put in place routinely without the patient knowing is abhorrent.

Of course they need to be included in the discussion. I am pretty disgusted that anyone could think otherwise TBH.

Doctors can decide this without a discussion with the patient/family. They do not have inform the patients or their family, but it would be "best practice" to communicate it. I used to work in hospital complaints.

OP. A DNR is a patient’s expression of their wishes.

No-one can sign one for someone with mental capacity without their express permission.

The key here seems to be that the person involved ‘hasn’t really had the opportunity to understand why a DNACPR was being suggested”. The dr should take time with this discussion and lead into it, not start with it as a sudden conversation. However, if the person was seriously ill, they may need to have the discussion sooner rather than later.
Active resuscitation is a medical decision as is any treatment. It is extremely brutal and the statistics of surviving resuscitation to the extent that you are fit to leave hospital is around 2/10. If you consider a person with frailty or advanced disease this figure will be likely much lower.
If there is no DNACPR decision documented there is likely to be a presumption in favour of resuscitation, which can be very traumatic, undignified and involve fractured ribs, with no meaningful survival ( ie no return to consciousness).
I’m sorry op if this sounds cold, I have seen many situations where resuscitation has been attempted in these situations and it is very distressing in my experience. If the heart of a fit person stopped unexpectedly this is very different as the cause is more likely reversible. But in a orson with advanced disease it isn’t often.

DNAR should always be discussed with the patient and their family if appropriate.

But it is a medical decision ultimately.

If someone strongly objects then that would be taken account of, but CPR on someone who is never going to survive it is a horribly disrespectful way for health professionals to assist someone to pass on and not a way any one of their family would choose if they really knew what it would entail.

So yes it's horrible and shocking to discuss it. But it's far nicer than the alternative.

They absolutely cannot HappyGirl86!

No wonder your hospital had complaints!

I am a nurse on an elderly care ward. Most patients have a DNAR in place or will put one in place after discussion with a Dr on the ward. However, all patients have the right to refuse - in which case CPR must be attempted in the event if a cardiac arrest.

I’m afraid there is some misinformation here. Look up Resuscitstion Council guidance 2016 if interested.

They would know.
I used to work in a residential home for the elderly and the residents were most definitely aware if they were DNACPR. It was a decision they had made.

Could the doctor have just made a mistake? Not ideal obviously.

Coffee runner I would check your policy as this would be unusual

Some are saying consent is necessary and others not. This is something I've never really thought about before and in a way I'm shocked that I don't know how something so important works.

It should be up to the patient.

But "some" consultants take it upon themselves, although this would be a purple form, but should still be signed by the patient.

One hospital told my mil they wouldnt resuscitate regardless... Another hospital said it was her decision and they done what she wanted.
When did have a cardiac arrest she was in the hospital where her decision was listen to. They managed to bring her back and put her on life support for afew hours, but her family got to say goodbye, so i was glad she was in that hospital and not the other one, because she would of died without her family there

Misinformation is an understatement
Why do people come on threads and post utter bullshit

I'm an ITU nurse and every decision is called by the consultant intensivist
Yes it's better to do it in agreement with the family but ultimately the consultant decides
And it's never a decision taken lightly

Different hospitals will have different policies op but please check guidance I suggested earlier. If the person strongly disagrees after discussion( which is rare in my experience when the discussion is clear) they can request a second opinion. If the person is insistent on resus although the medics can still sign DNACPR it is unlikely they would as would not want to cause distress. In the event if an arrest the attending team make that decision based on the situation.

I'm surprised at the nurses comments re right to refuse.....

As pp have said - it is ultimately a medical decision and can be made on the basis that it would be futile.

Yes, it is best practice to discuss this with the patient and/or their relatives/power of attorney but not a necessity for example in an emergency situation

In the case described, the Dr was making medical decision re the dnar however it sounds like he didn't communicate it very well and certainly didn't deal with the situation sensitively. But absolutely yes he should be discussing it in front of and more importantly with the patient.