Advanced directive or no DNR? Any advice?

[juatfornow]

My dad is having hip surgery tomorrow and at age 79 and with a couple of chronic conditions, he’s been told there’s a higher risk of complications. The pain he’s in is intolerable so he’s made the decision to go ahead - the family all support him in his choice.

I wonder if he’ll be asked to consider a DNR? I’ve talked it through with him and outside of the pain he’s currently in, he does have a decent quality of life. His view is that in the small chance of something going wrong, he wouldn’t want any life saving measures that might leave him worse off but at the same time, if there was a reasonable chance of being ok, he’d like them to do what was necessary.

I looked online and it seems that a typed ‘advance directive’ outlining his wishes would be better than a DNR. Does anyone have any experience in this? I’m just trying to give dad what he wants and I’m not sure on the best approach.

A DNACPR is only for use if his heart stops beating. It does not affect any other treatment, depending on comorbidities, CPR has a low success rate even in hospital. An advanced directive is a legally binding document stating what treatment you do not want. The decision to give treatment rests with the medical professionals in charge and will be based on multiple factors which will include the patient’s wishes.

They will likely ask. The likelihood of cpr working at this age is quite low.

So in theory, it’s probably best to not sign the DNR? Would that mean it’s then left to the medics to decide what’s clinically best? I think he’d be fine with that.

Ask if they use the ReSPECT process at his hospital (and if not why not) - it includes DNACPR but is more extensive and explanatory. But it should be a decent discussion to complete, not just a box ticking exercise.www.resus.org.uk/respect

If not a DNACPR is much more familiar and easier for a hospital/emergency clinician to understand and use in an emergency, and can be completed by the hospital.

If he/you are interested in doing an advance decision then Compassion in Dying have an excellent proforma, but it needs a bit of consideration to complete and to be properly witnessed to be legally binding.

I just checked and alas, they do not use the ReSPECT process.

With a DNAR in place they will do absolutely everything but try and restart his heart manually or de fib
cpr is brutal people think it’s like in tele they jump start them and next thing there sat having a cup of tea
damage it causes can be enormous will lasting complications and also there the worry of the brain being damaged by lack of oxygen

personally wouldn’t risk not having a DNAR

Anaesthetist pov - It’s unlikely they’ll decide to bring this up on the day if it’s elective surgery - they shouldn’t be doing the operation if they think needing cpr is a likely outcome. It’s slightly different in the emergency context (eg for surgery after a broken hip) but even then we often transiently suspend the advice to not resuscitate while someone’s in theatre because it’s one place where CPR has better outcomes (still pretty poor outcomes, but better than in lots of other scenarios). If he’s particularly worried he can discuss it with the anaesthetist on the day. If things don’t go smoothly in the post-op period it is worth keeping an open mind and re-visiting any discussion.

If the topic comes up - and it is very likely to - it’s best just to say what you said above. You don’t sign your own DNACPR, but they should be completed with discussion with the person (or their representatives if the person doesn’t have capacity). Ultimately all treatment - including resuscitation - is the decision of a clinician and a clinician can’t give treatment if they are sure it will be futile or not in the patient’s best interests.

When your dad is through the operation and feeling up to it it would be well worth having a good chat with him about his future wishes, maybe look at the advance directive form or ReSPECT forms, just so you have an idea of his views.

I think using the term “allow a natural death” is more appropriate than “refuse resuscitation” - resus is only ever an attempt, not a guarantee of more life, and there comes a moment when it’s just not going to work.

FWIW I’m under 70 and fit and well but have a very thorough Advance Decision in place.

One thing to remember as well, families do not have to signs dnr, it’s a medical decision and while the family should always be involved in discussions around applying it, ultimately it’s the medics who apply it and they do not need the families consent, though clearly best if everyone agrees. As previous post said, in this case, it’s unlikely they would carry out elective surgery if they thought cpr may be an issue

If there is no DNR in place your father would be resuscitated.

If your father is unsure then it is best that he discusses it with his doctors. They will likely be able to give him the best idea of whether he would have a good quality of life if he was resuscitated based on his comorbidities, age etc. CPR can be brutal, if it is unsuccessful then it is not a peaceful death, if it is successful then he may be left with much poorer health and quality of life. Ultimately the medical team makes the decision about a DNR not the individual (there is no signing required). However the medical team will take in to account the wishes of the patient and NOK and will usually go with the patient's wishes even if it's not what they are recommending.

An advanced directive is a good idea. It usually is more detailed and goes in to what treatment you would not wish to have in certain circumstances ( i.e would he want a PEG tube if left unable to swallow). However he would still need a TEP/RESPECT form as it needs to be a very clear yes/no to resuscitation.that can be read in a split second. Remember it is most likely that CPR will be carried out by Nurses or HCAs in the first instance and is very time critical so can't wait for a doctor to attend before starting. For this reason hospitals rarely have inpatients (especially elderly) without a DNR decision as staff are legally obliged to resuscitate with no form in place, even if it is not what's best for the person or what they want.

This is all very helpful, thank you!

I really appreciate you all taking the time to respond.

another anaesthetist. As per @Greybeardy we usually suspend DNAR forms around elective surgery as there are lots of ways we can temporarily kill you during anaesthesia & surgery.

Longer term it’s probably worth knowing that an ITU admission in the elderly usually results in an increase in dependency by one level
so: living independently becomes living at home with a care package,
care package at home becomes residential care
residential care becomes fully dependent nursing care.

Survival post cardiac arrest in hospital (but excluding the perioperative period) is quite low, and most survival pathways include an ICU stay.

I would recommend talking with your Dad and ensuring he has appointed a welfare power of attorney. You can help him bring up these topics with medical staff. In this situation I’d just go for it “My Dad wanted to discuss what would happen if he becomes unwell /deteriorates”.

I often did this for my Mum and my Dad’s last conversation with me was to remind me he wanted a natural death with no heroics. He got what I would call a good death with targeted interventions to relieve symptoms only.

To get this though as his daughter I had to face up to the reality and really advocate for his wishes with the intensivists (people I knew, some from medical school, or had worked with) who were considering ITU for him partly because he was young(ish), and partly because his final deterioration was so precipitate.

In general, I would say that the general public demand more aggressive care than most doctors would choose for themselves of their families and this influences provider behaviour. If when you raise sensible questions about attitudes to future treatment people get upset etc it acts as a disincentive to do so.

The GMC recently changed consent guidance and we are now meant to disclose all risks no matter how rare. One of the risks of routine anaesthesia is death. So we have to talk about it. But at least three of my colleagues have had formal complaints about doing so and many of us have had informal feedback that it was unwelcome. I feel a bit stuck between a rock and a hard place.

Just wanted to say thank you for all the helpful advice here - particularly to @greybeardyand @beatwix.Dad had his hip replacement yesterday and it went well. (who knows, perhaps one of you is my dad’s anaesthetist! Ha!).

Dad is classed as high risk because he has a serious heart condition but he had a spinal with no sedation and it went really well. As you both said, there was no talk of a DNR but it’s prompted a really good chat for the future. I have LPA and yesterday I worked with dad to advocate for what he wanted in terms of anaesthetic, a catheter and all the other things that go alongside somewhat more risky surgery.

They’ve got him in ICU just to keep an eye on him but he’s doing well and is itching to get on his feet after 6 months in a wheelchair. The surgeon said later that his hip was ‘utterly shot’ and he could see why dad was in such agony.

Thank you for your advice.