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

DNACPR is a clinical decision that the pt should be involved in but does not require consent.

It doesn't mean withdrawal of treatment

It literally means Do Not Attempt Cardio Pulmonary Resuscitation.

Do not try to restart the heart in the event of a cardiac arrest.

Because in most cases it will fail. And cause unnecessary trauma.

A pts mental faculties aren't really relevant to them being able to survive a cardiac arrest

All the more reason for the discussion to be done properly/thoroughly and preferably with a family member/trusted person present to aid with explanation and assist the patient in advocating for themselves.

My late DH had a DNR in place for the last two years of his life.
He suffered from severe heart disease which had gradually got worse and was affecting his way of life.He had previously been very active but had very restricted movements his heart was going on less than half full power.
It was heartbreaking but he said his quality of life was such that he no longer wanted to live.The doctor who put it in place told me that his heart was so damaged he would not survive the resuscitation process and the very act would kill him.
The part I hated most about it was having put what was known as ''The yellow envelope'' in a prominent place in the house so para medics would know not to resuscitate him.
All this still haunts me.

DNR is a clinical decision , best practice means it would have been discussed but the bottom line is it’s the decision of the clinician . DNR is totally different to do not treat it’s literally for if you have a cardiac arrest , it won’t affect other treatment being offered and the likelihood of an elderly frail person being successfully resuscitated is slim .

The important thing to remember is that a DNR does not mean "do not treat". If your relative falls ill she will receive any medical treatment she requires.

For a DNR to be in place it means a medical assessment was made and found that resuscitation is unlikely to be successful. I can't remember the facts now, but it's something like less than 20% of CPR attempts result in the heart restarting, and of those only something like 4% survive without complications. Those are the people who are relatively healthy otherwise. Your frail relative is very unlikely to survive with/after CPR.

The DNR is there for her dignity, and so the end of her life is not unnecessarily traumatic.

In Scotland so maybe not quite the same. My father was admitted suffering from pneumonia, he had advanced progressive MS. The doctor advised they would not resuscitate when the time came as it would be pointless because if they managed to get him back it woukd be temporary. They didn’t think the trauma that of resuscitation would be in his best interest.

If she's elderly and frail then it's unlikely she'd be a candidate for CPR either way, the DNACPR being in place just recognises that it wouldn't be appropriate - better to come to the decision carefully with time, as opposed to at the point when a person actually stops breathing.

It's the same as all tests and treatments, there is no requirement to provide any test or treatment which is not likely to be beneficial to a person, i,e. if you requested an MRI just because it was your preference to have one done you would be refused.

If a patient has mental capacity it's standard practice to inform them when a DNACPR is considered/put in place. Whether a patient has been informed on not is documented on the form. They're not secret, hence it being noted on discharge letter. A significant point of them is that family are aware so know what to do should the patient die at home - i.e. not encouraged by the 999 operator to do 10-20minutes CPR waiting for the ambulance crew for us to arrive and make a clinical decision that CPR isn't indicated.

If you're looking for more information or support regards this here:
www.nhs.uk/conditions/do-not-attempt-cardiopulmonary-resuscitation-dnacpr-decisions/

If this is happening often your hospital has to look at its processes. If clinicians aren't making sure this conversation is understood and retained they aren't acting acceptably.

Not in my/our experience I'm afraid. My DM came out of hospital with a DNR last year...she knew bugger all about it!

Same happened to my FIL; went into hospital with an infection, developed sepsis whilst in there and had episodes of delirium but was still discharged....WITH a DNR...which neither he nor my MIL or DH's family knew anything about!

Bloody disgusting. Yes, they SHOULD have a conversation with the patient on discharge but they don't always! Or they have a 'conversation' with the patient who has delirium, expecting them to understand what's going on?!

Sadly, this has happened (placing on dnr withour consent), particularly during covid.

DNR is a clinical decision, the patient or family should be informed, yes but it is ultimately the clinicians decision.

Being mentally fine doesn't really have anything to do with a patients outcome after cardiac arrest. I think people need to be much more aware of what a DNR means. It doesn't mean withdrawing treatment, it doesn't mean you can't be admitted for future illnesses, it just means that in the event of an arrest, you would not be resuscitated. Having been at many arrests I know that most do not have a good outcome, those that do usually require ITU care - frail, elderly patients are not ITU candidates.

As others have mentioned no consent is required. If a patient requests it from the gp it would probably be removed if you really pressed, although the factors that caused it to be implemented in the first place will still exist, so when they do have a cardiac arrest, as we all will do, the end result would be the same once a suitably qualified clinician arrives on scene and states that resuscitation efforts would be futile.

There are no blanket rules on when resuscitation is futile, but as an example in pre hospital terms with an out of hospital cardiac.arrest once a patient is over 65yrs old its vanishingly rare to get any response to cpr.

I really wish the reality of a cardiac arrest and subsequent resuscitation was shown accurately on television, It never is and unless you have ever been involved in one you will never know what horrible events they are. There is no way on this earth would I ever allow a resus attempt on any frail relative of mine!

They aren't good ICU candidates, but once tubed where do they go, down to ICU, where we flog them a bit longer, put a line in every vessel we can then we have to do down the "where are we going with this " and then discuss withdrawal of care! All because a DNR was not discussed timely. SPEAK TO YOUR RELATIVES!

Fuck's sake, another thread where people who know fuck all give crap health advice to the OP.

A DNR is meaningless if it hasn't been appropriately reviewed.

Just because a million people on Mumsnet do not want active resuscitaiotn when they are older does not mean the OP's relative should not be able to make the choice herself. In doing so, the consequences of her choice will be explained to her.

It's horrendous practice for a DNR to be in place without regular review, so perfectly acceptable for OP's relative to request that.

I've personally, in all my 35 years of work as a healthcare professional (now retired), never known a DNR to be put in place without the full backing of the person/family.

Maybe that's changed due to the modern NHS being utterly underfunded and encouraged to be shit by successive governments who want rid of it. But I somehow doubt it.

And if you have a relative in a residential or nursing home, who was there during covid - just check they are not still subject to the blanket DNRs that many residence managers allowed the government to foist on them during covid.

@ChristmasFluff my mum had a DNR against her and the family’s wishes , mainly because the NHS couldn’t be arsed to treat her , so it does happen .

@Floralnomad A DNR is not a do not treat! They are two separate issues
God knows why Dr & Nurses go to University when everyone knows better.

I'll bite on the Covid DNRs too.

Someone who is dead, as in their heart has stopped - resuscitation usually futile anyway, but in the few occasions it isn't, it's because it's started immediately. By the time the crash team got into level 2 PPE, the tiny chance of resuscitation being any use is gone and all the team would be doing would be torturing a dead person. And if they don't get into PPE, the chances of the team being infected with Covid during resuscitation of all things is enormously high. Yes there were some blanket DNR orders put out especially in the very early days long before vaccination, and I think it was a perfectly reasonable decision tbh, though I understand of course why they didn't last long. But I'm an extremist on this - I think anyone who wants resuscitation is fairly nuts.

I know that I’m an ex nurse , my point being they made mistakes then didn’t want to treat or resus - just excuse after excuse .

My disabled adult DD had a DNAR which was discussed with me by both the GP and a number of hospital consultants. (DD lacked capacity). Each time she was admitted to hospital the doctor checked that we still agreed with the DNAR . Pretty sure they'd have over ridden us if we'd said no but my point being it was discussed.

My DM did not have a DNAR but suddenly deteriorated during a hospital stay. The consultant rang me at home to ask if DM had expressed her wishes. I told him that she hadn't specifically but that I didn't feel that CPR would be appropriate and that my brothers agreed. The consultant was also in agreement and had no doubt already decided that but it was discussed with us as NOK.

@ChristmasFluff Loads of HCPs think DNACPRs are a good thing and should be very widely in place. I'm not sure why you're hinting otherwise. If you really worked as a healthcare professional you'd know how brutal resuscitation is and how low the chances of success.

@Moithered It's been said throughout the entire thread that in the UK, it is not consent based! That's how you end up with hellish situations like they have in the USA.

Look up Jahi McMath.

Sorry, what are you pointing out here?

@Moithered you went back to the idea that DNAR is based on consent, which is not the case in the UK.

Here it is a clinical decision, and that is overall better as it means a more realistic approach to care and prevents it being driven entirely by money, media, manipulation and litigation. The end point of that is easy to understand since we pretty much have an example of it: the United States of America.

@Innocenta omg that is horrendous! But I'm wondering how on earth a tonsillectomy bleed went untreated for dining. We get them back to theatre PDQ.