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.

I’m a hospital consultant. The decision to place a DNAR order on a patient is ultimately that of their medical team. It is good practice but not compulsory to discuss with the patient and relatives but there are obviously situations where this is not appropriate or feasible. Often a DNAR will be instituted by an admitting junior doctor overnight then reviewed in the morning by the consultant.

A patient can make an advanced directive if competent to do so that would prohibit CPR.

A patient cannot demand to have CPR when their doctor thinks it would be inappropriate or futile.

Thankfully the vast majority of the time the doctor, patient and relatives are all in agreement.

We had this last year about my mother. The doctors broached the subject of the DNAR with my father and me, and thankfully we knew mums wishes as this had recently been discussed as part of doing their health and welfare power of attorneys. She didn't want to be brought back if she had already died and/or risk some pretty brutal injuries like broken ribs and collapsed lungs in the process. It seems fair enough to me, I think I would want the same for myself.

When my mother had a massive stroke, the doctor brought the subject up with us (me and one of my sisters) at my mother's bedside. She was conscious but unable to speak. I was very unhappy and asked that we could discuss it elsewhere. I knew it was what my mother wanted and I promised her I'd do the right thing but I couldn't bear her to hear it in such a matter of fact way. It was 20 years ago but it still upsets me how terrified she must have been.

No one can demand a medical intervention. I cannot insist that I am put on the heart transplant list or have a skin biopsy.

Attempted cardiopulmonary resuscitation is a medical intervention. And unless there's a simple reversible explanation for the heart and breathing stopping (asthma attack, heart rhythm issue etc) then it is highly unlikely to be successful.

Sometimes people die because there is a sudden reversible fault - and CPR can be life saving.

Other people die because their bodies are exhausted by old age or cancer or chronic disease. CPR won't reverse that.

So a senior responsible doctor myst make a decision about whether CPR would be futile for every patient in the hospital. The fefaukt is to attempt CPR. But it a dereliction of duty not to spare a dying person from a pointless and intrusive physical attack by failing to make a do not attempt resuscitation decision. They should if possible discuss and explain to patients and relatives. But it is not a decision for the patient or relative to make and no one can insist that it is attempted.

There is a lot of confusion (even among medical professionals) as evident on this chat about DNAR. Any medical decision is the senior doctors to make, however in normal circumstances all treatment options are discussed with the patient and consent gained. A DNAR is no different, the patient should be involved and central to the decision. If the doctor questions the capacity of a patient to make this decision then they should complete a full capacity assessment recorded in the patients notes. If the patient is deemed to lack capacity and has family members that are appropriate to consult then their views should be sort, in addition to any beliefs wishes and feeling the patient may express or have expressed previously.

Quite often clinicians will not include the patient themselves in the discussion as they decide it would be too upsetting for the patient (this is actually against gmc guidance). They way in which you describe the doctor going about this discussion sounds very insensitive and against guidance. The discussion should have been with the patient (only including family members if the patient consents). The doctor should explain the benefits and burdens of the procedure fully. The decision to apply a DNAR should be on medical grounds only and not based on a presumption of 'quality of life' based on for example the patient having a cognitive impairment or learning disability as this would amount to discrimination.

This happened to my father. He’d been ill but expected to recover. Was in a care home convalescing before being discharged home; took a turn for the worst (unbeknown to us). We got a call saying saying he was ‘unwell’. Went to visit and on opening his room door he was literally gasping for breath, eyes wide that were pleading for help. I called an ambulance myself. Unpicked last few hours of his care to find the dr had written DNR across his care sheet! No discussion with any of us! The staff on duty had shut the door on him to leave him to die on his own. Coroners inquest. Police attended care home to collect the records (not straight away) No action taken. We still haven’t come to terms with his death.

OP, in answer to your question, Yes be very annoyed and discuss further!

Lots of confusion here.

As others have said CPR is a medical treatment and can be declined by a patient but not demanded. So you can request a DNA CPR for yourself or you can have an advance directive (legally binding) stating that you don’t want CPR.

But you can’t insist that you are offered CPR - that is a medical treatment and it can be withheld on the grounds that it is futile / harmful. CPR is very traumatic and much less successful than portrayed on TV. This decision should be discussed with patients unless they lack capacity or the discussion would cause serious harm (beyond “just” being upset). In this case it should be discussed with significant others and in the absence of friends / family a court appointed advocate. Usually agreement is reached between medical staff and families and patients. But it shouldn’t be a relatives decision - they should have input into it in terms of what their loved one would want if their loved one can’t express that - but the burden of responsibility lies with the medical team

Agreed China, it is awful when family are left feeling that they must make a decision about DNACPR. It is so unfair to burden them. Input about the persons values and wishes if lack capacity but certainly not to decide for them unless legal power to do so.
I wish these issues were spoken about more freely in life as then there wouldn’t be so much confusion

In addition, if they are discharged from hospital the DNAR is reviewed by the GP and a decision is made whether on not to continue to keep it active.

If the patient lives in a community/residential setting, each year the DNAR is updated as it has an 'expiry date' and all nurses/carers have an absolute poopy session trying to get the GP to review the DNAR before the expiry date.

Patients or their relatives can absolutely not insist that a HCP carries out CPR. It’s a bit worrying that some nurses on this thread seem to think they can.

DNAR is a decision made by the medical team, hopefully in consultation with and with the agreement of the patient/family.

For most of the public their only experience of CPR has been from watching Casualty or ER on tv. These scenarios are utterly unrealistic and portray a completely false picture of the efficacy of CPR. In reality it is brutal and rarely effective. Why anyone would want their elderly, sick relative put through a damaging and probably pointless procedure is beyond me.

BustedDreams I'm so sorry this happened.

The consultant may recommend DNR but in my experience most would respect the patient’s wishes to the contrary whether they were in sound mind or not. But this has to be agreed and discussed in advance and assumes the patient is comfortable challenging the consultant (many elderly people aren’t and will accept it).

However, when the DNR order needs to be decided after an event that leaves the patient unable to make a decision, the family’s decision doesn’t need to be considered.

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've had this with my brother. At first I thought the doctor was asking me if I would agree to DNR. It finally dawned on me that he was not asking me, he was telling me that the decision had been made. My brother was unconscious anyway and in no fit state to join the discussion. I was actually quite relieved that it was not my decision. I knew that he would not survive the underlying illness for long anyway.
I was satisfied with the way it was dealt with by the medical staff.

I work in a country where the DNR must be agreed by the patient (if they have capacity) so I find the idea of not discussing it with them or only telling family to be abhorrent. It sounds like the doctors bedside manner was poor and perhaps your relative does not understand the severity of their situation. People are often shocked when doctors sit them down and explain that things are not going well and resuscitation would not be in their best interests. Often this is preceded by a long illness when there has been much contact with healthcare professionals but no meaningful conversation about prognosis. I’m not saying this is your relatives experience but it may be, so something to consider.

There are DNR forms routinely applied to patients in the A&E I work in, and it's a medical decision. Some families have highly unrealistic expectations of what resuscitating a relative or attempting to actually means and the likelihood of success. Whilst a family should be involved, unless they applied for and won a court order, you can't force a medical team to resuscitate a family member as far as I'm aware.

I’m an icu dr.

Whether or not CPR or other resus measures are offered is a medical decision. We simply cannot offer futile treatment. It is entirely unethical.

Any competent patient can of course refuse CPR or other resus measures, even when it is medically appropriate to offer them.

There are many times when families demand ‘everything’ for their elderly or frail or seriously ill relative. They have no idea what ‘everything’ looks like, and they don’t get to make me torture their 95 year old mother.

There are also many grey areas. For example, if you have emphysema it may not be appropriate to offer you intubation if your lung disease worsens, but entirely appropriate to intubate you to facilitate life-saving surgery.

It is best if the patient and family agree, and get the chance to talk openly about what they would like the end of their life to look like.

Its not always the patients choice. The consultant in charge of care can bring the subject up, but it should be a discussion. Im a nurse in A+E, I see this discussion happening daily.

Granted though, some dr's bedside manner is appaling which makes a big difference

My 85 year old mum was really ill last winter, pneumonia and septicaemia. She was confused and delirious and on an acute geriatric ward. Visiting was after 11 and, when we arrived, was told the consultant had discussed and she'd signed a DNR. We felt she'd been railroaded into this - and she had.

It would be absolutely her decision, but so was so Ill and feeling a burden on the nhs. We honestly didn't think she'd be walking out of that hospital, her vital signs were grim. She shouldn't have been asked to sign this alone. She has terrible hearing and often just agrees with people she doesn't hear.

I love the nhs. They are the reason she survived this bought of illness, but she could so easily have died. I know we all have to die at some point, but she's precious to us. It was the wrong time to ask her imo.

SOme serious misunderstanding and misinformation.
Do not attempt cardiopulmonary resuscitation is a way of protecting patients from inappropriate and overzealous care. It allows a dignified and natural death instead of broken ribs and tubes at a point when resuscitation would be futile.

Trusts have marginally different policies but are broadly the same.

It is a clinical decision. Usually a decision made by a more junior doctor has to be signed off by a consultant within 24 hours. Consent is not necessary as it is about not giving specific treatment rather than giving treatment. Much as you wouldn’t consent to not having chemotherapy if it wasn’t in your best interests and wasn’t likely to be effective- but hopefully the medical team would explain why.

The guidance is that the decision around CPR should be discussed with any patient with capacity to be involved. There is no obligation for family to be involved if the patient chooses not to. Families should be informed and involved where a patient lacks the capacity- but they are not consenting.

Most resuscitation attempts are unsuccessful- despite what is portrayed on casualty. Something like 10% of patients are resuscitated successfully- although many of those don’t jump up and start dancing.

In acute illness the decision should be kept under review as the patients condition changes - so a younger patient in ITU, for example.
Most hospices won’t admit patients where end of life discussions have not taken place and a DNACPR is not in place.

DNACPR is not the same as stopping all treatment. It refers simply to withholding intervention if the heart stops beating. The person should still receive treatment for conditions other than that - urinary tract infections, broken leg, burns etc. Withholding all active treatment is a separate discussion.

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.

Of course consent is not necessary. Otherwise people who are in the hospital to die but haven't put one in place would have to have COR which would be idiotic. In many cases it would only hurt the person and they would still die in a short while. CPR needs to make sense before they break all the ribs (happens frequently with CPR) just for someone to live a few days longer in a lot of pain.

About 10 years ago we had a flick through the notes of elderly close relative (they were stored at the end of the bed), and were surprised to find a DNR in there. It hadn't been discussed with us (next of kin), but we thought it was the right decision anyway under the circumstances. I've another elderly relative who you'd have to be a sadist to try and resuscitate - no way would it do any good.

The OPs situation does sound like it has been insensitively handled though.

I am a medical ethicist.

Patients who are capable of consenting can refuse any kind of treatment, including life saving treatment. This also means they can sign a DNR.

This is quite different from a right to request treatment. Patients do NOT have the right to demand treatment that medical professionals have decided will be futile in their case. So if the doctors think that resuscitation would be futile then they are not obliged to offer it even if the patient wants it. This means that doctors can sign DNRs without patient agreement. However, it is good practice to discuss doctor DNR recommendations with the patient in a sensitive and appropriate manner, to make sure they understand what might happen and why.

Ok, the picture has become clearer from this, thank you.

I can see that the doctors don't need anyone's consent to make this decision as it's a medical one, but that it's probably best practice to discuss it with the patient where the patient has capacity and it won't otherwise do them harm to have the conversation.

With this knowledge though, I do think our situation has been mishandled, since the sensitivity was lacking.

Furthermore, how it looks to me is this, not just from the DNAR but from other aspects of the care so far. From the family perspective, we know that the patient was very recently well and active. We are expecting her to recover to her usual self. However her current illness has caused her some temporary confusion and obviously she's a bit weak etc. (Pretty much like I was last week when I had flu - no one presented me with my end of life options!) From the perspective of the doctors, it seems like they feel as though here is a confused frail older person who is probably always like that and may not improve. I think their communications have really been framed from the medical staff lacking perspective on how the patient usually is. So obviously discussing a DNAR when as far as you're concerned you've got a couple of minor, fixable issues is a strange and scary shock for everyone.

I take your point about the insensitive approach and you may want to discuss this with PALS to make sure communication is better handled in the future.

However a medical decision for DNR is not usually made because the doctors think the resus would be successful but pointless because they don't value the patient's life as they are frail and old. In the vast majority of cases the resus is unlikely to succeed so it's not deemed to be in the patient's best interests to put them through this. And don't forget that patients who have minor, fixable issues are not likely to need resus in the first place, your relative would need to go into heart failure to need resus in the first place.

I was the one who found it distressing in DH's case - he was asked his views and said he wanted a DNR when the time came. I was devastated but in his case it had to be his decision, even though he had a brain tumour and wasn't classed as of sound mind legally. He was lucid enough for that decision at the time it was taken.