Do Not Resuscitate order - urgent help needed

[DorsetCamping]

DM (74) has been in hospital since Monday with severe dehydration, anaemia, high potassium levels and acute kidney injury.

She has not been well for some time with various conditions but has enjoyed a reasonable quality of life - in her own home and driving.

Over the last few days, she has become increasingly confused, distressed and drowsy which is so difficult to witness as obviously I'm not allowed in to see her. We have had a few Zoom calls but it's not the same.

I've just had a call from a doctor who says that despite various scans and tests they cannot work out what is happening and DM declining. Scans have not shown up anything and feel it may be down to conflicting meds for all her conditions which has put her system out of balance. She has now been taken off of all pre-existing meds.

Out of the blue the doctor then said that as mum 'has a poor quality of life' it was her opinion that a DNR should be put in place although they were still continuing treat and hoped she may pick up.

This is a huge shock to me - the doctor just didnt seem to get that DM actually had a pretty good quality of life before this kicked off, rather she is a frail, very poorly old lady who should be put out of her misery.

I am next of kin, DM is in no state to make her wishes known (although on previous hospital admissions had always been adamant that all reasonable efforts are made to resuscitate, should it need to happen). Can I insist that no such order is put in place, certainly not in the short term?

I am besides myself with worry and that the hospital are just happy to let her slip away. I have been granted a visit, which I know full well the implications of, in these lockdown times.

Your mum can still have escalation of all treatment but a DNAR is only if her heart stops naturally cos they don't think rescusitation is right. Thinking of you, talk to them about her escalation xx

Yes! You can insist on this.

Whilst you can insist on being involved in the conversation about it, it is not your choice and your views whilst they should be listened to don’t change the fact that it is a clinical decision usually based on likely futility.

If you think this is what she would have wanted you can insist, but resuscitation is a brutal procedure.

No. Neither your mother nor you can demand a treatment which is what CPR is. What you can do is discuss your concerns with her medical team and they have a responsibility to give your their reasons as to why they think CPR would not be beneficial in your mothers case. It is a terrible time to have an ill / critically ill family member especially in the current circumstances. I hope your mother is comfortable and begins to improve soon. The hospital trust I work in has a good information booklet about CPR aimed at families and patients. As a PP mentioned it doesn't mean she won't be treated only that they will not provide CPR if she were to pass away. Sorry OP.

Thank you for your replies. I accept I have to realistic. It just came out of the blue and came across almost as if they were withdrawing treatment. I certainly don't want to put her through a futile and traumatic procedure but want every effort made to help her recover

You can’t insist she is resuscitated if the medical decision is that it’s a futile treatment . But you can insist it’s discussed with you again and poor quality of life now should not be the reason why it’s withheld unless everyone is confident that’s what your mum wants / is in her best interests. You could also ask for a second opinion.
I’m sorry you’re in this position. Resuscitation is a brutal treatment with very poor success rates when there isn’t a reversible cause of the arrest. So it’s great if, for example, you have a heart attack and your heart rhythm becomes abnormal but can be shocked back to normal. Useless if you are dying of an underlying illness process which can’t be fixed. It may be that’s what they think is happening for your mum and hence the discussion around DNACPR. But it sounds like you need to talk through this more st the very least and you should have the chance to do that

A DNAR is actually called a DNACPR - do not attempt cardio pulmonary resuscitation. It doesn't mean anything about any other treatment.

Your mum will still be treated for other conditions. It just means that if her heart stops, they don't think it's in her best interests to try to resuscitate. Chest compressions are brutal and nothing like shown on TV, so if resuscitation was successful (and it only has a low survival rate) it's hard to recover from.

A DNR doesn’t mean stopping treatment and having your mum “put out of her misery”, it just means that if her heart were to stop they wouldn’t do CPR.

CPR can be very traumatic for anyone, let alone older people, and can often leave them with life changing injuries if they survive. A DNR is put in place to prevent this.

Of course you can argue it, but look into it thoroughly first and think about your mums quality of life if she was to have broken ribs, or brain damage, or other injuries following brutal resuscitation.

It must have been a shock. I feel for you.

Sorry, when I wrote you can insist I meant you can insist, but the decision will be with medical staff.

You can absolutely insist on her not having a DNR, and those wishes would be taken into account, however as other posters have said, it would be a clinical decision as to how much intervention would be done.

The problem at the moment is that doctors are having to make these decisions without much other information other than the patient in front of them, but it's absolutely relevant that your mum before her decline was active, and the issue seems to be that they simply don't know what is wrong with her, rather than a condition that would require a significant amount of intervention.

Resuscitation is brutal, very very undignified and often does not work. It is not like on TV .
Having a DNAR does not mean that not everything else would be done as they are obviously trying to sort out her medical problems. What it meant is that if she got to the point where her heart stopped because she is so Ill that it can no longer work they would let her have a peaceful death rather than a whole team jumping on her and putting her through a horrendous ordeal at the end.
I am sorry your mum is unwell and I hope they can get on top of the problem soon.

You can't insist as it's a medical decision, but you can absolutely discuss your concerns and emphasise the quality of life your Mum had before this illness. You need to feel all the information has been considered.
Just a thought, was the doctor referring to quality of life before this illness or after should resuscitation happen?
What I mean is for resuscitation to occur your Mum would have to be so overwhelmed by her current illness that her body systems failed and her heart stopped and she died. Even if the resuscitation restarted her heart (which would be unlikely) she would likely be in the same position she was before her heart stopped but probably worse as 'down time' when the heart isn't beating can cause damage to organs including the kidneys and brain. It sounds like the doctor has concerns regarding her quality of life after resuscitation.
I'm sorry if that sounds so bleak.
Whether to resuscitate has nothing to do with the value of the person or their life, it has to do with the possibility of them having a meaningful recovery after. Your Mum's life is worth as much as anyone of any age, but it will come to an end at some point.
I'm sorry you are going through this. Talk and talk to her medical team, make sure you say what you want to say and that you feel all decisions have your Mum's best interests at the heart of them.

Sorry to hear about your DM

Please don’t confuse not attempting resuscitation (DNAR) with withdrawal of treatment they are not the same. The new RESPECT process here makes this clear.
Ask to discuss it again when you go in.

Thank you
I can visit her for an hour at 4.30 so hopefully I can get a better perspective of how she is. This has all happened so suddenly I feel like I'm in a dream

This isn't about with drawal of treatment as others have said but its about should her heart stop whether or not they let her die or resuscitate her.

We had this when Mum was nearing her end - in that Dad and Mum had discussed it previously and said no, but with a wider discussion (without Mums input at this point as she wasn't capable) we made the point to Dad that if her heart did stop she had died, CPR would be bringing her back from that to what...(in our case vascular dementia) and that it would be a violent end should it not work and what was wanted above all else was a peaceful passing away.

I think they are maybe prempting things a little early HOWEVER at the moment DNRs are very front of mind due to the nature of Covid 19 which causes clots and strokes which is perhaps why they are asking earlier to get it on record - it doesn't take long to sort but it is an official letter rather than just the three initials on file

Yes you can oppose them putting a DNR in place. I don’t want to dampen the mood but doctors do not always put the patient first, many doctors simply see a patient as taking up bed space and do not want to waste money and resources on older people. This happened with my grandma to the point where we had grounds to sue and the hospital she was in had a rule legally changed to ensure that what happened to her did not happen to other patients.

I am not saying that this is what is happening in your personal situation, but please keep yourself very informed of you and your mother’s rights and do what you think she would have wanted.

Following as we have had the same issue recently with an elderly relative. 83 with various lung issues but all there mentally. She told the doctors she did NOT want a DNR. When she was discharged, they found a DNR letter in her file.

@PersephoneandHades your post is offensive to medical professionals and I've reported it.

OP, it is a clinical decision. Ethics state that your mother's best interests drive this decision. That does not equate to your best interests.

Please do some reading before you visit your mother.

Very sorry to hear she's so unwell.

I didn't think her post was offensive, and I could say more, but that doesn't help the OP.

I too have reported that post as its extremely offensive

Doctors absolutely do not view patients as just taking up beds.

I’m really sorry to hear your mum is so unwell, hard at the best of times but particularly so right now when hospital visiting and seeing other family for support is so restricted. Really glad you’re getting to see her today.

As others have said, a DNACPR order just says that resuscitation won’t be attempted, so if your mother’s heart was to stop beating she would be allowed to die with dignity rather than going through brutal resuscitation efforts that would be unlikely to bring her back. It doesn’t mean that that any treatments (potentially all treatment including ICU care, dialysis etc if this was thought likely to help) apart from CPR will be offered.

The decision not to give CPR is a medical one and in my opinion (intensive care doctor) the decision whether a patient should have CPR or not should be made for every patient when they’re admitted to hospital and re-assessed throughout their admission and I think since covid this is happening more and more - having the discussion should not imply that the patient is potentially coming to the end of their life but that everyone knows and understands that for patient x, CPR would be a horrendous thing to put them through that almost certainly wouldn’t work, and for patient y, CPR would still be horrendous but has a hope of working and leaving them with a good quality of life afterwards. On a positive note, I’ve been involved in discussions with families regarding limitations of treatment (no CPR, no ICU and so on) and many of these patients have subsequently been discharged from hospital and are still going strong but know that when they reach the end of their life no one is going to carry out futile, painful and distressing treatment.

My mum had an ITU admission last year with a DNA CPR. Consultant felt she wouldn’t survive mechanical ventilation or CPR so didn’t offer those treatments. She still had excellent ITU care and nursing (and recovered)

I also object to the comment that “many doctors” see patients as taking up bed spaces. I can’t say no one does, because I don’t know all doctors, but the vast, vast majority absolutely have their patients’ best interests at heart.

The other aspect is that a 74 year old, looking after themselves, driving etc & seeming ok, is very different from a 54 year old. As we age, our resilience and ability to bounce back from illness, reduces, but this isn't something you can see or measure when someone seems well. Multiple conditions needing medications which then have potential to interact, don't help of course.

It's not uncommon in 70s and 80s for an illness which would have been shrugged off at 55, to prove unrecoverable from. This is bewildering for relatives, of course, and can seem 'ageist' when heroic treatments are advised against - it's not directly due to age, but due to the impact of age on ability to recover from illness.

I hope your mum's decline stops, and she can be built back up to her previous self.