Any medical people around that can explain DNR to me?

[Sweetheart]

My dad is in hospital in very poor health. He is still conscious but very confused. The hospital have asked us as his family to consider a dnr. His dr and nursing team all think he should have one. The dr has told us if he needed cpr he wouldn't survive.

My dad said previously he wanted to live as long as possible.

What are the advantages of having a dnr?

They're discussing it with you to get your thoughts, as that it's good practice, but actually it's not your decision. Some teams make it sound like it is, which is unfair. Medically, your dad should not be offered a treatment, nor can you or he demand it, when it won't work. For is a medical treatment that only sometimes works in healthy people. Basically, they're trying to tell you cpr is not on offer.

Ultimately, it's not your decision, it's not your dad's decision, it's a medical team decision. But it's good practice to get your thoughts. Dnacpr forms are protection against indignity, inappropriate treatment and a prolonged horrible death. Basically, if your dad died (his heart stops), he won't have attempts to restart it, mainly because those attempts are brutal, and won't bring him back to life. It won't change anything unless he dies.

But don't let them make you feel like you're deciding this, they are deciding this, and just want your input. You are not responsible. I would take the team's advice, though.

I'm sorry your dad is so ill.

If someone's heart has stopped though surly they wouldn't be able to feel the cpr anyway?

I’m sorry you’re having to go through this

If it helps in the UK legally this isn’t a decision for you to make. It always needs to be in discussion with you but ultimately it’s not up to you - it’s the doctors decision to make based on their clinical judgment.

If it’s something you really oppose then obviously explain that to them and they’ll unlikely sign it but if it isn’t it might make you feel better to just tell them to do what they think is best. That way you won’t feel any ‘guilt’ of taking a treatment path away from him. I don’t know if I’m explaining that properly but I had it once put to a family that it was their decision and it caused days of agonising talks between them as they felt they were giving up on someone while staff were extremely stressed at the thought of potentially having to perform brutal CPR on a clearly dying person whose comfort and dignity should’ve been priority.

I’ve been there. I think the way people feel about wanting to live as long as possible is very different when they have good quality of life compared to when they have none. I too wanted my mum to live as long as possible, until she deteriorated to the point she could not eat, was still vomiting various bodily fluids and had no chance of recovery. She essentially starved to death over the course of five weeks and it was horrific - resuscitating her when she died would have the height of cruelty,

I think that it depends whether there is any reasonable expectation that he could survive this illness and have decent quality of life. If he would just be resuscitated, which is brutal, to spend a few more days or weeks suffering with no quality of life, it seems cruel to extend his suffering in this way. Sometimes death isn’t the worst thing that can happen to someone, and it took me seeing my mum in that state to understand this.

Sending you love and support, it’s such a hard thing to go through x

sweet that's not always the case. The compressions if done well give some circulation to the brain. Unfortunately they also cause pain and break ribs in many cases.

It's not what they feel, but the after effects.

Your father, confused and generally frail, will have a brain devoid of oxygen for however many minutes it took to revive him, bruising from the chest compressions, intubation and defibrillator paddles and broken ribs with possibly punctured lungs.

He'd spend his final days intubated, in HDU, wired up to machinery alarming every time his heartbeat went below a certain point or his saturation levels dropped, and he'd be in immense pain.

DNR is the kindest thing in some cases.

By doing cpr, you perfuse the brain, that's the point of it. So, yes, cod would be very painful while you die. Sorry. It's not something that's worth a shot, as it would do no harm. It is painful (broken ruins), undignified (stripped quickly), and a nasty way to die. If the heart is restarted, temporarily, he may not be considered for itu care, so would just be waiting, likely as a vegetable, to die again.

Dnacprs are good things.

*ribs, not ruins.

CPR in reality is not like on TV. It is brutal, undignified, cold and noisy. There will be up to 10 people around the bed, your father will be naked and clothes cut off if necessary. In all likelihood you will not be able to hold his hand or tell him you love him.
The chances of resuscitation being successful (getting a pulse back) are slim and then what next? I doubt an intensive care unit will admit someone who is in an irreversible premorbid state.
No CPR does not mean no treatment, there can still be antibiotics, fluids, pain relief and other medications as needed.
Ultimately the choice to apply a DNR rests with the consultant but best practice strongly recommended patient and family involvement in the decision

My extremely fit 50 year old husband had a cardiac arrest and was resuscitated. It was brutal, it is not like you see it on the TV people rarely survive and if they do they often have long term damage. My husband was in a coma for a month and remains in a minimally conscious state over a year later. Would you want your father to go through that? I sometimes think he would have preferred not to be resuscitated and we now have a DNAR in place.

If they manage to get his heart started again his body will have gone through massive trauma with very probably irrepairable damage. He could end up dying in a lot of pain and a shell of the person he was. I understand this is a very horrible time for you but which would you prefer? To slip away peacefully it to be pounded back to life which could leave you nothing like you were?

So sorry you are going through this.

With regard to whether you feel pain, I guess that also depends on whether you are conscious/aware. But in theory your brain lives after your heart stops (hence CPR being possible), and so in theory you would be feeling pain, your heart doesn't need to beat to carry pain, it's nerve endings etc.

But if CPR is successful, your Dad would certainly feel the pain of the CPR damage, and possibly have brain damage as well.

Maybe chat with the doctors and say you understand they will make the decision based on their medical expertise, but your Dad wants to be given every chance to pull through this.

If they are talking to you about DNR then it is likely that they think that his body will need constant medical support to keep him alive in the near future. They probably feel that he is unlikely to be able to make the decision himself and so you, as next of kin, should be asked. He might also have already decided how he wants to be treated and have a document that sets out his wishes. You, as next of kin, would hopfully know about this, if it exists.

Advanced life directives often cover
Breathing support - tubes down the throat to pump oxygen
Cardiac support - pacemaker style electrical control for the heart
Antibiotic support - managing infections that might end life
Nutrition support - tube feeding
Fluid support - saline drips to prevent dehydration
Maybe other ones

You can agree to some, all or none of these. You can also put a time limit on any of them. Ie. breathing support for 10 days to see if he can recover it on his own.

Well no, they won't feel it during the CPR but they will feel the after effects if resuscitation is successful and could have broken ribs, or brian damage from their heart being stopped too long etc.

He might not feel any pain while CPR was ongoing but if it was successful he would after - and he might therefore be in pain and not live for much longer if there is likely to be another stopping of his heart or breathing.

I would talk to his doctors OP and try to get a better idea of why they have made this recommendation - ask them to explain to you why they think CPR would be unlikely to work and what the advantages of a DNR are. It will help you to decide how you feel about it if you have more information, I think. You're entitled to have the whole process explained to you very thoroughly before you come to any view on it.

OP I'm sorry you are going through this

Re CPR, the thing is they will likely break his ribs - it's the pressure on the chest - and put a tube in his throat - his body will feel pain as soon as he comes back into consciousness.

Oh halfacup, I’m so very sorry - what an awful situation. Sending love

A Dnacpr is not a "give up" form. It's about one treatment, which has a poor success rate. He'll still get every treatment going that could make him better. What they're saying is cpr isn't one of those treatments.

I hope he recovers quickly. Please talk to the medical team, they should be used to these questions.

Mum had a DNR and made sure everyone in the hospital (for a non life threatening issue) knew about it - but they still 'worked' on her when she died (of fucking superbug which she got in the hospital in the first place).

I’ve oeformed CPR on many elderly people that relatives have refused to agree on a DNR. It’s bloody awful for everyone concerned.

I’ve felt their ribs break. Doing something that if they do survive it will probably mean their last days are spent in agony, with chest infections leading to pneumonia because they can’t cough due to pain and are immobile.

The elderly don’t tend to live long after CPR because effectively their heart giving up is the body saying it’s hard enough.

I’d never inflict CPR on anyone that is frail, unwell and elderly in my family. The first thing I did when my Nan went into hospital very unwell was too make sure she didn’t have to suffer the brutality and indignity of CPR.

It is nothing like on television. Your dad will be stripped pretty much naked, he will have needles going into him wherever until they manage to get blood....this in itself will be difficult because of his age and his body is shutting down, he will have his chest crushed by more than one person because it’s very very tiring doing CPR. It’s really horrific when done on the elderly because you know that for the majority it won’t work or their life will be very short afterwards and they will be in immense pain.

so sorry to hear this OP.

Basically apart from some particular circumstances if someone's heart stops beating (cardiac arrest) it is very unlikely that they will survive whatever you do. If you were outside of a hospital and this happened they would die. In a hospital where they are being monitored there is the chance that you could perform CPR. This is highly unlikely to keep them alive for any significant length of time and can be very traumatic but in the absence of a specific DNR order the hospital staff must attempt to resuscitate the patient.

Everyone I knows who has experience of resuscitation from within a hospital environment almost always insists they absolutely would not want this performed on them and would go for a DNR.

Sorry you’re going through this OP

We went through this with my DM, she was so poorly and we knew she would pass, we (DF, DSis’s & I) couldn’t bear the thought of her going through CPR, DSis is a Nurse and had been very frank about what would happen.

In the end she just slipped away over about 17 hours, it was so peaceful and we were able to sit round and talk to her and tell her how much we loved her. DF has asked for a DNR when the time comes.

CPR is a vicious brutal thing to do to a a very sick elderly person. It literally feels like mush after you break through their ribs. The recovery from that is almost non existent for an elderly person not to mention the prospect of pneumonia contracted post CPR because of the broken ribs.

I personally would have a DNR if that's what the Doctors recommend.

Essentially there is a reason your heart stops beating. If you are young and healthy and the reason is to do with some kind of trauma, or you have had a heart attack due to a blockage the reason for the cardiac arrest can be reversed (if they manage to resuscitate you).

If you're very old or very sick sadly and your cardiac arrest was due to these issues even if they can get your heart to temporarily start beating again they can't resolve the issue which caused it to stop in the first place so it is 100% inevitable that the problem will reoccur until it eventually kills you.

There are two common misconceptions about DNR. I will address both.

1. "DNR means 'do not treat'; they'll just leave him in bed to rot."

NOT true AT ALL. Example: I used to work in a hospice. ALL of our patients were DNR. We worked VERY hard to keep them comfortable. Active medical conditions can still be treated. Pain and distressing symptoms (e.g. shortness of breath) can be treated. ALL DNR means is that if a patient's heart stopped, they would not get CPR. That's it.

1. "CPR would be successful. They're just writing Dad off."

CPR is successful in older people (65 years +) less than 1% of the time. In the vast majority of cases, death doesn't occur suddenly. The heart stopping is the last step in a sequence of events during which the body progressively shuts down. By the time the heart stops, there is literally no one left to save - the rest of the body is already gone.

In my area, we don't have a blanket DNR. Rather, we have something called "goals of care". Patients can choose from 3 levels of resuscitative care (full CPR, artificial respiration only, or medications and ICU treatment only), 2 levels of medical care (treat active medical conditions, may do surgery, but no CPR and no ICU admission), or 2 levels of comfort care (treat symptoms only).

When you consider that CPR is treatment, it doesn't have to be offered to patients who are unlikely to benefit from it. A doctor wouldn't put you on an antibiotic if you didn't have an infection, right? If it's unlikely your father would benefit from CPR, a DNR is completely appropriate.