DNR request - prepare for worst?

[AFriendlyVouce]

If a hospital calls and asks next of kin to agree a DNR recommendation- is that a sign to prepare for the worst, or just a box ticking exercise?

Parent is in hospital. Long and complicated situation, but has been going very downhill over a week since having a surgical procedure and now has an infection on top.

They've been taken pretty far away, I'm currently alone with the kids whilst DH is working abroad and I've just had that call from the hospital. The Dr was very polite but their English wasn't easy to understand and they were very cagey when I kept asking directly if this meant a serious risk of death.

It just seems odd to me that they'd ask this if it wasn't likely to be needed.

I was asked if there was one in place when elderly relative was admitted last week. There is no risk of imminent death.

Sorry posted too soon.

Relative does have one in place but if they didn't perhaps the doctors would have been looking for it to be arranged.

Hospital had this conversation with my DM when DF was admitted to hospital almost 2 years ago with mobility issues. DF still living.

I suspect there is a box-ticking element to it, but it would no doubt be reassuring for you to be able to discuss this properly with a member of staff at the hospital. It must be a worry, especially being so far away from him.

Thank you, that's reassuring

They may be asking because they have discussed this with your relative too and they all feel,they wouldn't benefit from artifical life support in the event their heart stops. It doesn't mean they will not receive any treatment, food, drinks, medication, they may feel there is nothing to be gained and its best to let nature take its course. It is a medical decision, next of kin has no legal meaning here but they prefer to discuss it with the family, even with power of attorney you cannot demand treatment. I would call the nurses and ask them for an update if you can't get hold of the doctor.

It depends. It can be either or both in different situations.

It can be part of general medical care in that a ceiling of care should usually be decided for all patients and discussed with family as appropriate. So elderly frail patients should have DNR form even when not acutely ill, just as a decision that CPR would not be appropriate.

In the event of deterioration and becoming very unwell in hospital it becomes important to think and discuss if the person would benefit from intensive care escalation for organ support or CPR ( separate decisions).

The two things are slightly separate- is my relative deteriorating / not expected to recover and is my relative strong enough / young enough to benefit from ITU etc or is the more conservative management appropriate

It means that in the event of a cardiac arrest the normal CPR (resuscitation) would not be carried out as it is unlikely to be of benefit. It can be very brutal usually resulting in broken ribs and where a patient is very elderly or very frail it’s may be more suitable and dignified to not do this especially if it is deemed unlikely to work. It doesn’t necessarily mean death is imminent it just means they are pretty frail/poorly/elderly and so there is a considered plan in place if they were to arrest. The order has to be signed by 2 doctors and renewed every few months usually.

Sorry that is a bit garbled I'm tired apologies

My gran has been DNR for about the last decade.

it doesn’t mean they won’t receive treatment for illnesses, only that docs won’t do CPR in the event of cardiac arrest. For an elderly person CPR often doesn’t extend life at all or not beyond a few days, very compromised, and means that the person’s last moments are spent having a very painful and distressing procedure rather than being allowed to die more peacefully.

It’s fine to ask questions. I’d also recommend a book called The Book about Getting Older by Dr Lucy Pollock which explains it all very well.

It does not mean imminent risk of dying. It's more about being realist about someone's condition and what their outcome would be if they were to seriously deteriorate and need resuscitation. Takes into consideration current medical problems, co-morbidities, frailty etc.

Just from my recent experience, my dad was poorly in intensive care a couple of weeks ago with sepsis and various other complications from a sudden illness.
He went into ICU one day, the doctors asked us to consider a DNR the next day as he was in organ failure and he passed away two days later.
But, when we had the DNR conversation they were very clear that he was gravely ill and very unlikely to recover. They worked really hard to manage our expectations throughout.
It may be a positive if they haven’t indicated that he is in immediate danger.

Thank you, yes the Dr said something about Co morbidities making it not recommended

That's the problem - they wouldn't say they weren't gravely in danger but wouldn't say they were. I asked a number of times very directly and kept being told "your parent is really quite ill" which sounds so soft for having just been asked for permission to DNR! But this DR did not speak overly great English and my feeling was it was a bit lost in translation and they were trying to cushion the blow. I asked if I needed to come (it's far away and I'm alone with kids) and they said they'd let me know- which isn't saying yes at the moment, but isn't saying I won't need to either.

your parent is really quite ill. Sorry to have to say this, but “really quite ill” is a lot more serious in the mouth of a doctor. Hopefully they will recover, but meanwhile if practicable make sure you’ve done everything you need to to not feel guilty later. Try and talk to a nurse - even though aspiring doctors get lessons in communication, nurses tend to be better at it.

I got asked if I had one myself when I had an operation on my leg; I was 35 and no other health problems!!

The DNR discussion is routine for elderly patients but I agree that 'really quite ill' rings warning bells (I had two elderly parents in and out of hospital for years). I would also try to have a frank phone call with a nurse or doctor on the ward.

This - as the doctor said to me - it's not like on the TV, it's brutal and we will break his ribs"

My mum fell and broke her ribs, she also has a replacement heart valve. In A&E the dr asked if we wanted a DNR as attempts to resuscitate would be brutal on her body. She’s 70 and was there because she had an accident not a terminal illness so we said no. The dr was from the elderly care team and I wonder if it’s a question they ask all of their patients.

Any doctor saying 'really quite ill' generally means very very ill.

I would take this as a serious warning sign.

DNR discussions should be routine on admission to hospital for older people. I'm pretty sure there is guidance about it (I don't work with adults anymore)

I think it's important that people start thinking about it.

I'm a doctor. As I get older I definitely want to be DNR. I have made my wishes very clear to those who might be asked about them in the event that I get mashed cycling to work. I probably need to formally nominate attorneys and write it down.

Most doctors make very conservative decisions about treatment. It's rare for us to pursue "experimental" or "last ditch" options. There was a good US article about this a few years ago.