To ask how DNR works in England.

[Summersun2000]

Help please- in a different part of the UK from England so want to check this. A relative in England has had DNR put on her discharge form but is apparently bright and from what the family says, has capacity.
She did not realise this and wants it taken off.
Does she just ask the GP/ district nurse directly to do this? She is physically frail but apparently mentally fine. Thanks

Yes she needs to contact her GP and ask for it to be removed. She also needs to be contacting PILS at the hospital she was discharged from and make a massive complaint! Outrageous that they put that on there without proper discussion!

They would have had a conversation with her and she would have consented. You can't have a DNR without consent.

If she wants it removed she just needs to contact doctor/GP to have it removed

Not in England but in Wales, but the guidance is the same. PP is right, contact her GP to have it removed, but I would also recommend contacting the Trust directly, and making a complaint at the same time. That's really bad - DNR decisions are ultimately made by the treating medical staff (usually registrar level or above) but they should always have discussed it with the patient first, and also filled in a DNR form recording why.

The law does not require consent for a DNA, it is a clinical decision however the law does state that the patient should be consulted and their wishes considered (although those wishes do not need to be part of the decision), the reasoning for the DNA should be explained too. If you're not happy that a DNA has been applied then you can ask for the decision to be reviewed by another doctor however they may agree with the first.

I'd definitely contact PALS and look at the hospital complaints procedure as it sounds like the decision has not been discussed properly with your relative.

Thanks- this is what I thought. A family member is now saying by text that the document is several years old- so that would mean the DNR has carried through to her discharge form!?
If the conversation was several years ago she definitely would not have consented as she has remained fairly fit until the last couple of years.
We will ask her to call her GP tomorrow if she wants it removed.

As said DNR is a clinical decision and doesn't require family ok for it to be in place. A discussion should happen though.

Please be aware that resuscitation isn't like it is shown on TV. It causes broken bones and trauma. For elderly people, if they survive the resus, the damage done can totally remove their quality of life.

Even if a person says they want to be resuscitated it doesn't mean it will happen - in the moment if the treating clinician decides it would be futile then they won't to do it, in the best interests of the patient. Generally speaking, resuscitation attempts aren't successful anyway and I don't think people know what they are asking for when they insist they want it, it's not pretty or dignified at all.

If she is frail it may be that DNR is the best decision for her even if she doesn't like it.

If the medical team believe there is no chance of successful resuscitation then it is their decision. They should inform you unless there are strong reasons not to - it being an upsetting conversation is not a good enough reason.

Resuscitation only applies effectively when you die, is a brutal procedure and is exceptionally rarely successful especially in the elderly, frail and those with other health problems.

I'd advise your relative to have an open minded discussion with her GP about what she really wants when she dies.

Decisions about resuscitation are ultimately up to the clinicians, not the patient or the patients' family. It's quite different from America (and most doctors feel our approach is much more humane) where aggressive resuscitation is often inappropriately done.

However she can still query it and even complain if she wants to.

But @AnnaMagnani is correct that if she is frail, DNAR is likely the better option anyway. Most people do not understand the reality of resuscitation.

Just out of curiosity, what is the families concerns around the DNAR?

What do they think the benefits of removing it/cons of it being live may be?

Having worked in a hospital i would ,like others point out that recus has its issues and I would research.
However, a dnr should always be discussed.maybe your relative didnt understand / overwhelmed at the time of discussion , which can be common.. time to re assess...?

It's unacceptable that they didn't discuss the DNACPR with her. It doesn't matter what we think about CPR and whether we would choose or recommend it; if we are not offering it because someone is frail or doesn't have the reserves to survive CPR then as clinicians we must discuss this with them unless it would cause them significant physical or psychological harm to do so.

The clinicians discussing it with the relative should have made sure that she understood.

Having had many people tell me DNACPR wasn't discussed, usually when you look at the notes it was.

Hospital admissions are busy times when you are feeling ill, tired, meeting loads of different professionals and getting a lot of new information. It's not surprising one conversation gets forgotten.

PrawnToast5- agreed.

My mother was asked by a nurse about a D.N.R. we explained what it meant, and she said quite clearly that she wanted to live as long as possible ( she was 94! ) we noticed later that her notes had D.N.R. written on them. She was quite ill and died a few weeks later, after another admission to hospital, but discussion and consultation seemed a pointless box ticking exercise in her case.

If I'm having a cardiac arrest, I would like to be allowed to die without someone breaking my ribcage. I would like to die without that extra pain, thanks. That is why I would take a DNAR now, and I'm not even 60 yet.
Having a DNAR does not mean that the staff will not treat you (for infection, sepsis etc) just that they will not do CPR.

My elderly mum who had heart problems requested a DNAR a few years ago when she had capacity. She made it clear that she did not wish her life to be prolonged and end up in a nappy, not recognising her nearest and dearest.
I think more people should discuss this with their families, and ensure they are able to have a dignified passing when their time comes

Resuscitation is brutal and often futile so if you're relative is frail it may be the best option for her tbh.

It's a TEP form now anyway (treatment escalation plan) which has more details about what your relative may or may not want. For example they may want admission to hospital for IV antibiotics but not for full resuscitation in event of a cardiac arrest or should she die peacefully in her sleep.

TEP forms are the way it's done in the trust I work in.

And like many have said, CPR isn't a gentle procedure.

She really needs to think about what resuscitation actually involves. And does she want to put her self through that, if she was to go into cardiac arrest. Many people thinks it means no treatment at all. It doesn't. Everything will be done except trying to restart the heart if it stops. Obviously though she needs to complain that it was not discussed with her.

And If she is frail it really may not be in her best interests. The chances of ROSC with no sequela are very very small.

I'm 40 and not sure I ever want CPR if there is no realistic chance of survival with a good outcome.

It’s a medical decision, not a patient or family one, although the individuals wishes should be considered, absolutely.

A DNR just says if you’re already dead (no pulse/heart stopped) we won’t do chest compressions to try to get a pulse back. A DNR doesn’t stop them providing medical care in advance to stop you getting to the point of a cardiac arrest.

There’s a whole host of “post-arrest” care required to get a patient from “return of spontaneous circulation” back to a busy meaningful life, including intubation, ventilators, big cannulas into the neck, assessment of organ function and many blood tests, scans, and if you get that far, physio and occupational therapy, etc. Most of which is incredibly invasive, hard on the body and in a lot of cases totally futile. It’s rare that young, fit and healthy people survive a cardiac arrest, and rarer still in the elderly or frail - no matter how mentally sharp they are.