DNR ..who’s decision?

[Winterpetal]

I have LPOA for relative in a care home
relative has good quality of life
care home has phoned me to say the doctor has put DNR on relatives notes and they need me to come in to sign the paperwork.
i have had LPOA for past 4 years and always said no to this when asked .
this is a relatively new rest home ,relative has moved to ,and now it seems I’m not getting a choice about DNR.
i have said I’m not happy about it ,but I’ve had 2 phone calls this week asking me to come in to sign the paperwork.
can the doctor and care home over rule me ?

I deal with this daily and find it very frustrating when families do not agree with the dnacpr. We always try to get families to agree but sometimes we do ask the doctors to make the final decision. CPR is pretty much futile in the over 75s, especially with co-morbities and frailty. In the small chance it does work, they are left with very little quality of life and likely to die shortly afterwards. Not only is it awful for the patient, it is also horrific for the staff in the care home. It is very very traumatic for everyone involved.

Imagine dying peacefully in your sleep when you've had a reasonable quality of life, then having several people jumping on your chest and shoving tubes down your throat, giving you electric shocks. For you to come back unable to walk, talk, feed yourself and completely incontinent. Then to die of the subsequent chest infection caused by your broken ribs from the cpr.

Remind yourself that whilst your relative might have a good quality of life right now, elderly people can go downhill very rapidly. A simple kidney infection can see them hospitalised and lead to further complications (which is what happened to my grandad). After two and a half weeks he was a shell of the man he was and we were actually very happy that there was a DNR in place. He would have had no quality of life.

A DNR is not a licence to bump someone off or not give them adequate care, even though that’s what it might feel like. Would your opinion change if they had terminal cancer, or a debilitating stroke, or a heart attack that left them with limited mental capacity, or an infection that led to sepsis and required surgery (but would be unlikely to survive surgery)?

I think you may just be missing some communication from the doctor / home here which is making it harder to process. There will be good reason as to why it has been added to her notes but it’s poor form that they haven’t explained why.

It’s hard to get your head around at first. I think medical dramas have a lot to answer for tbh. We think doctors can save anyone. Take some time to let it sink in. Ask for a factual discussion, and reframe it as a decision in your relatives best interests.

I have given POA to my sons, and told them they are never to feel forced into taking any responsibility for a decision they dont want to take.

Having POA does not mean you have to act, you dont have to do or sign anything

In the circumstances when it becomes an issue, the attending doctor can make any decision

Care home said ,it is because she has dementia and because she had bowel cancer years ago.

relative and I had absolutely no discussion about what she would want ,there is no other family .
she is just a bit forgetful,but not frail at all ,busy and active all day ,

sounds like you can have the conversation with her then, and record her wishes

Care Home insisted DNR signed by my DM who did not want to sign it. She was 89 and had worked as a nurse then in a care home 🙄
she always said ‘stick me in a home when I get old’ then really did not want to go.
But was talked round eventually.

A DNR doesn't mean they are on palliative care or will get no treatment.

If she got a urine infection or chest infection they would still treat her with antibiotics, the same if she developed something like high BP, they still treat it.

All a DNR means is in the event of sudden cardiac arrest eg, if she had a heart attack or massive stroke/bleed they wouldn't attempt aggressive resuscitation. it won't affect her current or ongoing care, it just means staff aren't forced to attempt futile measures .

CPR in elderly people is very rarely successful and even if they do get a return of circulation you are looking at broken ribs, and punctured lungs. It's not a treatment, it doesn't cure whatever caused the collapse in the first place. You could be bringing them back to still die of whatever was the reason for the collapse in the first place, only this time they are in pain and suffering due to the trauma of the CPR.
It sounds like the DNR decision has been made and they just want your signature to say you are aware it's in place.

Resuscitating someone with dementia is infinitely more cruel than allowing them to die a natural death.

We had this discussion with the palliative care team for my late DH last year. At the time he was 6ft 3, physically strong and 18 stone (steroid weight) and only 55.

Our wonderful palliative nurse explained that CPR has to be brutal to work and that if the patient either has co-morbidities or is older the likelihood of it working is slim. He discussed how, if my DH were to need CPR and it worked, he would likely be in a permanently worse physical state after it than before. It was a brutal, distressing conversation to have, as kind heartedly as our nurse explained it, but ultimately I was so grateful to have it laid out for us. We signed.

Seconding this ^

It's very tough but it's the right thing in most cases

Everyone seems to be saying the same thing on here
i need to rethink

Thankyou ,everyone who took the time to reply ,I really appreciate it ,I will go in tomorrow and have the conversation and do the right thing .

You don’t have to agree if you think that your relative wouldn’t have wanted it. You really don’t. It feels like an awful decision to make on her behalf if it goes against what you think her wishes would have been. All the stuff that other posters say is true but if your relative is living a happy and contented life, albeit with dementia, and you think she would want another chance at living, then don’t sign. You could ask for a few weeks to think it over as well and give yourself some space to understand the implications of both courses of action. I don’t have a strong view either way but I don’t think you should be pressured into doing something you feel uncomfortable about.

If she needs to live in a care home she is by nature frail. Dementia is most definitely a contributing factor to frailty.

CPR is pretty brutal as referred to countless times upthread, and for a frail elderly person in a nursing home already is highly unlikely to lead to a good outcome.
Would this relative of yours really want that for herself or would she rather she was allowed to slip away peacefully in that situation? I was fortunate to be able to discuss these various scenarios with my late parents as part of setting up their health and welfare POAs, and both were very much of the "let me go" viewpoint.

I don't think there's anything remotely controversial about this, it's about being realistic when it comes to possibly subjecting them to a very brutal treatment to bring them back when they're already very frail with a limited life expectancy and no doubt other health issues. Would that really be in their best interests?

My parents both had a DNR in place, nothing to do with me, and even when my DM was admitted to a rest home - and she had mild dementia - they asked her, not me (I was there at the time and had an EPOA for health/welfare).

That aside, why on earth would you want to put an elderly person through CPR? As others have said it is brutal. There was a thread on here a while ago from someone who had performed CPR on an elderly person (at his wife's request) and after the way his life was after that they felt very guilty about doing it.

My DF died yesterday, and was very ready to go - he had told this to numerous people. If I had begged the hospital to keep him alive for longer at any cost he would have been distraught. As it was he passed away very peacefully and pain free, which was what he wished for.

The risk of brain damage in resuscitations is often underestimated. I have a friend who was resuscitated and because she'd been starved of oxygen for some time before resuscitation, has been left severely disabled as a result. She was in her early 20s too. It'd have been kinder to let her go because she has next to no quality of life now and that was in a young healthy person.

I’m sorry for your loss @magicthree

The previous post has reminded me of a young man who had an accident here, decades ago. CPR was performed and he lived until fairly recently, but never worked again, had lots of health issues over the years and was brain damaged. The person who performed the CPR once stated that looking back he wished he hadn't done so, as the man had very little quality of life.

I think it is worth you going in to present the case that you feel your relative has a good quality of life despite her dementia. Agree that CPR specifically would not be appropriate, because it would be traumatic, unlikely to succeed, and probably leave her with a drastically reduced qualify of life if it did succeed, and sign the DNACPR form.

But do get it on the record that other less brutal life-prolonging interventions very much would be worthwhile.

It should have been discussed properly with you before being signed, with the medic explaining exactly why CPR would not benefit your relative. They will still actively medically treat them but if they’re heart stops they won’t restart it (it’s not how tv and the movies portray it, people don’t magically wake up fine after a round of cpr, it’s brutal). My gran is in her 90s, mobile and independent and in great health. I would still agree with a DNAR and so would she. There’s a lot to be said with being aloud to die a dignified death, even more so when it’s unexpected.
the media loves to act like a DNAR is a death notice. I promise really isn’t.

Thank you @Stoechas He was 89 and not enjoying life much in the last couple of months, so while I am very sad I feel happy for him that he is now at peace.

DNACPR is just that -- don't attempt CardioPulmonary Resuscitation.

CPR is only relevant when someone's heart has actually stopped. It takes only moments after that for the brain to start to die.

So CPR is not a question of keeping someone alive; it's actually trying to resuscitate them and bring them back to life in the few minutes after they have died. In very elderly folk, the commonest reason for the heart to stop is simply that they've reached the end of their life, with everything winding down.
CPR is really only attempting to delay the inevitable. Perhaps, OP, if you think of it like that, then a DNACPR ruling might seem less "cruel"?

I think you should book and appointment with the GP to discuss DNACPR and treatment escalation if the home aren't willing to discuss it and just want you to sign. CPR is a medical decision and can be made by the doctor but it is important it is discussed with you and you understand why the decision has been made.

I'm a nurse in acute medicine and I do CPR on a regular basis and there is absolutely no way that I would want it if I was elderly, frail or had multiple comorbidities. Out of hospital cardiac arrest is successful in less than 10% of cases. Obviously people who are younger and fitter are much more likely to survive so that makes the odds very unlikely for someone who has needs that require a care home. I have never seen someone achieve return of spontaneous circulation without a need for an intensive care and someone with limited mobility/multiple comorbidities/frailty/cognitive impairment would not be a suitable candidate for an ICU bed because being sedated/ventilated/assisted to eat/breathe/catheterised etc takes a massive toll on the body and its unlikely they would a/survive it and b/have any quality of life following a significant amount of time in cardiac arrest (by the time ambulance transfer to hospital).

If your loved one has capacity it's probably a good time (while they are well) to have a discussion about what they would want if they were to become unwell. People's perspectives change as they get towards the latter stage of life and not everyone wants everything available.

The majority of controversy around DNACPR decisions is poor communication and this sounds no different. I know its tempting to not engage because they have dealt with this so badly and not sign the form but having been part of the resuscitation of people who would never be fit to make it a survivable event I would have the discussion. It is absolutely not how you would want your loved one to pass.