To ask your opinion in DNR?

[susandelgado]

My mil, a wonderful lady of 85, is in hospital for what seems to be the last time. They can't treat her many conditions any longer 😐 She was approached this morning by a registrar, who said he had spoken to her family and they wanted to put a DNR on her notes. He explained to her what it meant and she agreed, as she's had enough of it all and doesn't want to fight any more.
The thing is, this has NOT been discussed with her children, and they were very upset when they found out. They fully agree that it's her choice, but not the underhanded way in which it was done.
It makes me very angry, and seems almost negligent on the hospital's part, why the hell couldn't they have told the family first? They have power of attorney for medical matters.
Has this happened to anyone else?

He should not be saying that he had spoken to family members when he (or anyone else) hadn't.

Had her capacity been assessed for this decision? Ultimately yes, it is a medical decision, but her capacity (capacity is time and issue specific) to be involved in this decision should be assessed using the capacity assessment for complex decisions. If she has capacity then her views and wishes should be ascertained before the decision is made. If she is assessed as lacking capacity around the decision, then family views should be sought, and again, they should be involved in the decision making process, although to confirm - this is a decision that ultimately a doctor makes. If a person lacks capacity and has no family or friends that can be consulted, then a referral to an independent mental capacity advocate should be made.

It's obviously difficult to know what has been done in this situation. Hopefully a capacity assessment was done, and if she has capacity then it sounds like her views were being sought at this point. This wouldn't be discussed with the family at this point if the person has capacity. Even if they have LPA for health and welfare this would only be triggered if she lacked capacity. However it is clear that he was wrong to say that family had been consulted when they hadn't. it's unlikely to be viewed as negligence though, as it has not been detrimental to her health (ie no serious harm has come to her due to his actions) and ultimately her views are being respected within the decision making process.

It sounds like a miscommunication - it wouldn’t be a case of what the family wants, a DNR is put in place when the medical team think heroic measures aren’t in the patient’s best interest.
Could he have said something like ‘we’ve discussed it’ and she’s assumed he meant with family?

@5foot5

I admitted I misread the OP (read it too hastily!) and agree that they shouldn’t have said they discussed it with the family when they hadn’t.

Regarding DNRs though - whilst doctors may have a discussion with the family regarding DNARs they’re technically not asking for consent. It is a clinical decision not a family one. It is respectful to have the discussion though at an appropriate time to avoid any distress or confusion.

My loved one was in intensive care and it was clear that he wasn’t going to recover. The medical team phrased it to me that I needed to tell them my preference on how to proceed, should his heart stop. They also said that if it came to it they would work in his best interests.

Tbh for me, that was the kindest way that they could have approached that conversation with me. When medical care was withdrawn, it didn’t feel like I had made the decision so to speak. In the two years since, with the profound grief and sadness I have felt, I feel like I’m not responsible for him dying. Rather, it was a collaborative decision taken in his best interests.

Sorry. It’s all a bit raw so I don’t know if I’ve explained that very well. My point is, is that imo this should be a collaborative agreement between the patient (if they’re capable), the medical professionals and family members if appropriate.

Reginabambina a family agreeing with a DNAR is not "letting someone die when possible" it is a family not wanting a loved one to go through an extremely brutal procedure, which at her age with no doubt various comorbidities she would almost certainly not survive. If she did survive she would wake up in ICU, surrounded by equipment, almost certainly to die sometime soon after. Even the fittest, healthiest people stand only a small chance of surviving CPR. In an elderly, frail person it is almost certainly pointless, and any family or medic would be cruel to suggest it should be attempted IMHO. I have seen heartbreaking situations where there has been no DNAR in place, and paramedics have been obliged to carry out CPR on very frail, elderly people.

whilst it is clearly probably in the best interests of most 85yo frail and unwell people to have a DNR on their notes, the issue here is the lying.

as pp say the final call is a medical decision anyway but lying about it can cause genuine harm

she probably doesn't have long left. a doctor telling her that they have discussed the question with her family and everyone thinks she should agree to the DNR when this it's not the case is a horrible thing to do to anyone during their last days of life, and could fracture relationships and cause horrific heartache that might never heal if the 85yo took offence at being told this and blamed their family members.

your MIL is clearly lovely and wouldn't react that way but that is sheer luck and doesn't make the lying any less unethical.

I think a complaint to PALS is appropriate emphasising that its not the decision you contest but that the lies were unacceptable.

There was a thread in the last week or so with similar

Here is is www.mumsnet.com/Talk/am_i_being_unreasonable/3798103-Doctors-SHOULDN-T-get-to-play-God-AIBU

My mum insisted that, knowing all this, SHE STILL WANTED TO BE RESUSCITATED.
We requested the medical/nursing care notes as we were not happy with her care. When they arrived, I was really shocked to read the A&E notes in which the admitting Dr stated that both Mrs X and her Next of Kin (daughter) agreed NOT TO RESUSCITATE. I’m fucking furious. I never said that/signed to that. My mother never said that/signed to that. Remember, she was in for tests and physio. She NEVER expected to die. Neither did the family.

A couple of bits from the thread. It seems the doctor didn't tell the truth there either.

@AutumnRose1, the problem is that the doctor told her he had already discussed this OP's MiL's family and they had agreed, and that was not true.

oh sorry

my insomnia is showing

he said he had spoken to the family.

ignore me.

Yes what @Oulu said.

If an 85 yo thought that all her family thought it was the thing to do, then she might go along with it.

It's not fair for the doctor to lie. It's emotional manipulation. You should be able to trust your doctor to be truthful.

We have had another thread on this subject where the family think they should have been consulted. It is actually a medical decision although generally it is didcussed. Families have no idea about what resuscitation actually entails, breaking ribs etc, very traumatic and largely unsuccessful. It is largely just a courtesy so families dont expect American Hospital Drama if there should be a collapse. This deoes not mean removal of care and medicine, but just not aggressive futile heroics

It is in this ladies interests to be left in piece. The family should put this first and foremost instead of all this indignation. Who would be a doctor in this day and age?

In the quote from the previous post, Mum could not insist that she be resuscitated, it is not her decision

My father in law thought he was having a heart attack. Went to the hospital. They told him he was fine. He went home. 2 days later he got a call to say they’d mixed his blood test up with someone else and he did indeed have had a very severe heart attack

I went into a and e having horrific pains in my back. Struggling to breathe. Dr came in. Didn’t even ask me any questions. Didn’t even look at me. Barked at me that I was having a panic attack and when my breathing slowed I’d be sent home. Breathing finally slowed according to him sufficiently. He sent me on my way. Again. No questions. Nothing. I collapsed on the way out. Fortunalty an amazing dr found me collapsed in the hallway and correctly diagnosed I was having a PE. Turns out I had massive bilateral pulmonary embolisms. Had I of followed the original drs advice. I’d be dead. As would my father in law

Mistakes are made.

I wouldn't be happy to think that the situation had been discussed with relatives by medical staff without the patient being aware of the planned conversation. The decision is up to the patient not the rest of the family as long as the patient has the mental capacity to decide.

Before we demonise the registrar, has anyone stopped to think maybe MIL misunderstood or misheard the conversation?

Something along the lines of “have you had a discussion with your family about resuscitation?” and not “we’ve had a discussion with your family about resuscitation”.

Of course it may be that the reg was totally out of order. But before accusations, complaints and outrage are expressed it helps to know that actual content of the conversation.

I would be trying to find out exactly what was said and to who rather than just assuming.

TBH I think that families should discuss this stuff anyway, because often when you come to the point of DNR it’s a very sudden situation so not as simple as just sitting by and watching as they do nothing.

As an aside, I have had CPR and at 45 I can categorically state that it was the most traumatic time of my life and the pain and damage done to my ribs and chest for weeks after was indescribable. And I was lucky, I didn’t sustain a punctured lung - something which isn’t uncommon.

As such I actually think that performing cpr on a fail 85 year old is barbaric, and as hard as it is I think that dr’s should look more in the direction of DNR in those situations.

For the record, she does have capacity, she's very sharp, and the family are totally on board with her decision. I know that it's totally up to the doctors, but did they have to lie to her and let her believe that her family had already ok'd it ? That's what makes me angry 😡
I've been at the hospital with her all afternoon, that's why I haven't been able to answer. I will read all the replies after I've driven home.

The key thing here is what the patient wants, of her own free will, since she has capacity.

I have always believed in the theory of 'My body, my choice'.
The thing that really decided me was when my DD, as a student nurse, did a placement on a geriatric ward, and I had to comfort her when she came home after performing CPR on an elderly lady.
Her tears as she spoke of feeling the fragile ribs snapping under her hands with every compression, while the senior staff urged her to keep going, made the decision very easy...

They have very clearly been underhand and I don't think people are reading the OP properly: the registrar told the patient that the family had been consulted and wanted a DNR.

First: that wasn't true because the family had not been consulted
Second: the family should never be consulted on this without the patient's express knowledge and consent
Third: the family's wishes, even if they had gone to the doctor and told him, should never have been communicated to the patient by him.

This is all kinds of wrong. I would get the name of the registrar and report him to PALS.

Sorry to hear she is poorly. A family cannot expect to be told first. It is a medical decision and if a patient has capacity to make a choice not to be rescusitated that is their choice. Even if a patient lacks capacity and has poa the doctors make the final decision based on the clinical position. No one can insist on treatment being given
Best practice is to discuss the patients condition and wishes with the family but sometimes patients will tell the doctor not to speak to relatives or pretend that they have and everyone is on board. Theres no negligence and poa for health when someone has capacity makes no difference.