No CPR order

[GipsyDanger]

Families In The Dark Over 'No CPR' Order
news.sky.com/story/1688569/families-in-the-dark-over-no-cpr-order

I don't know how to feel about this. Basically the gist of the article is that some patients who are dying are having a 'no cpr order' without the patient OR or the family knowing. I am very fortunate that I've never had to experience this first hand, but how can they do this? I know the doctor is the professional that it may cause more harm than good (supposedly). I honestly don't know, but surly even if it's in the best interests of the patient - the patient or guardian/carer should be told.

Life doesn't last forever, its often in the best interests of the patient for the doctor to just let them pass peacefully. I have looked after several relatives at their end of life and sometimes the efforts to keep someone alive can only be described as torture. Why would telling a relative make any difference, surely it would only distress them more. A lot of people refuse to accept a life has come to its end and try to force the doctor to keep them alive when the doctor know they can't and doing so actually hurts the patient even more.

Just come to terms that life is precious but not eternal.

I agree with you OP. They seem to have had these DNR (Do Not Resusitate) notices for a long time. The Daily Mail kicks up a fuss about it but it still carries on and now we are told it may affect 20% of patients whose families are not told.

Hopefully some of our great and good will do something to change this, but I somehow doubt they will.

resuscitate

Urban, they should discuss it with the patient at the very least, as the Addenbrookes case which went to court clarified. In fact, in that case, the Trust was found to be acting unlawfully by not discussing it with the patient. Doctors should not be able to make that decision without the family/person themselves being involved (unless that is entirely impossible).

Urban fox
I'd also rather someone drift off peacefully rather than be kept alive in pain (I'm of the 'wouldn't put an animal through it why a human' camp) but it's the not telling anyone I'm not sure I'm comfortable with.

Some reasons the patient may not be told: Dementia, confusion, in a coma, distressed at end of life.
Reasons family may not be told: patient does not consent for family to be told, family not contactable or have asked not to be contacted in the middle of the night.
These all count towards the statistics.
I agree that a discussion should be had with patient and family wherever possible otherwise.

I would have thought that under the principles of informed consent, then either the patient (or their next of kin if the patient is considered incapable of consenting) would have to agree to a Do Not Resuscitate order?

A 'do not attempt cpr' order basically means if someone's heart stops beating, so, if they die, people will not do chest compressions or put a breathing tube down their throat or put needles into their veins or their bone to give them drugs.

It doesn't mean they won't be treated if they're ill, it won't mean they will be left to suffer pain or discomfort, it won't mean they will be denied food or drink. It just means that when they reach the end of their life they will be allowed to die.

CPR is horrible, brutal, undignified and rarely successful. It's horrific to do it to someone when you know it's the wrong thing to do. If someone is clearly approaching the end of their life - if they have terminal cancer for example, it's clear to the medical team looking after them that they will die at some point and that trying to bring them back after they've died is the wrong thing to do. Sometimes talking through this is distressing for patients and their families. Sometimes the conversation is unnecessary - if someone is going to a hospice to die or is having intensive care withdrawn at the end of their life because treatment isn't working, there is no need to have the discussion that when the heart stops beating we won't try to start it again.

Doctors are not wandering round the wards secretly writing dnacpr forms in random peoples notes just cause they don't want to look after them any more. Generally it will be discussed with the patient and their family. But sometimes it's clear a patient is reaching the end of their life and, although this will be discussed with the family, the fact that once they die we will accept that they have died doesn't need to be spelled out. The form still needs to be in the notes though so when the patient passes away the team caring for them know what they do and don't need to do.

We know that even when the patient gives consent the family often overrides it. As is the case with organ donation. I can see the its a catch 22, what do the doctors do then?

Whether or not to attempt cpr is the decision of the medical team caring for the patient. It's not a case of informed consent (in any case, once a patient is over 18 the next of kin have no legal ability to consent or otherwise for medical treatment), it's a case of assessing whether a patient's heart has stopped beating due to a potentially reversible cause or if their heart has stopped beating because they have died.

Dear OP,
As a HCP I think there are several reasons why a discussion about whether or not to attempt resuscitation may not be had with a patient or their family. The law is clear that there is a strong presumption in favour of the decision being discussed with patients and/or NOK. It is important to note that CPR is a treatment that should not be offered if it would be futile and therefore the principal of informed consent does not apply in this case. It is ultimately up to the Dr and medical team to decide if it is appropriate to offer CPR as a treatment. They should however discuss this with the patient and family (if the patient consents or lacks capacity). So why is this not done on too many occasions? Sometimes the patient lacks capacity and families can't be contacted (this is relatively unusual) sometimes the medical team find it hard to admit they can't "cure" the patient and so put off having the conversation. There is also still quite a paternalistic approach to patients in some areas meaning that decisions are made and not discussed because the staff don't want to upset the patient or family member, related to this is also the fact that we find these discussions distressing too and so can avoid them to protect ourselves. None of these reasons are ultimately acceptable reasons not to have these vital discussions but they have to be viewed in the wider context of a society that finds talking about death and dying difficult. And so as a HCP who has had to have too many of these conversations with distressed patients and their relatives can I urge you, if you haven't already done so, to speak to your loved ones about what you might want in this situation. As a HCP I am not asking you to take responsibility for raising these issues with your HCP (unless you want to of course) but if you have already thought about what you want it makes the discussion a little bit easier for everyone. For those of you who might need a bit of help with these issues can I point you in the direction of the Dying Matters website and the Dying Matters awareness week (9th -16th May). Xx www.dyingmatters.org.uk

When a DNACPR order is in place the family/next of kin cannot over ride it, even in the community/nursing home etc, so long as it is valid.

I still find that people still do not understand that a DNACPR does not mean that treatment is denied, it only applies when a person is in cardiac arrest which is not the same as a heart attack.

Surely, if there is a 'NO CPR order' then it means that the patient is dying and very little can be done for them.
Should that not be discussed with the patient and the patient told about it?

I fully agree with Princess that these are very hard conversations to have and that it's not unusual for doctors to prefer to 'sell' their hope card rather than telling their patients they have very little time left.

But 20% is a hell of a lot and I would really want to be sure that these 'orders' are put in place when it is the best thing to do for the patient, I've they are actually told about it rather than imposed on them.
Note: what is the best thing to do might well be a different thing for the patient and for the doctor. Some people will want to have everything done until the end, incl CPR. Others would probably prefer to not have surgery/treatment/CPR when the hope it will make any difference is very low, even if their doctor thinks it is worth trying.

Princess, I am going to do what you've advised. My family have never talked about what we'd do in that situation. Just because the topic is unpleasant doesn't justify not taking about it.

And thanks for all the hard work you do

My MIL was given one last year without prior consent or without informing any of her family.it was the right thing for her though as she was very ill and would not have survived CPR.

It was a shock when we came across it, I stumbled across it when packing up her belonging to move her to nursing home when she was in hospital. It had been issues 3 months earlier.

She was issued a new one every time she went into hospital, she was in and out for 6 months before she died.

It's something I am certainly going to consider putting in place when I'm approaching 80 or if I develop a life limiting condition before then.
Having carried out numerous resuscitation attempts and only been completely successful in 2 over the past 7 years I know just how unlikely a good outcome is.
It's such a brutal thing to carry out, caving in rib cages and drilling into bones to give drugs and the older you get the less likely it is to be successful.

Can I ask the HCP here why on earth it is ever done if is so brutal and has little success?

Because it sometimes works, I do it in the out of hospital environment where the chances are more limited, no bystander CPR or ineffective CPR plus the reasons for the collapse may not be easily treated out of hospital.

The times when it is most successful tend to be where there are people able and willing to carry out CPR immediately to a high standard which is not that common. The two where I have been successful, by that I mean the patient was revived and had no brain damage, were both witnessed by me and so treatment could begin instantly.
Seconds really do count.

Gipsy, I am delighted that you are planning to talk to your loved ones about this.
Life, if I were you I wouldn't wait that long because as you know life can sometimes be unpredictable and unfair and you wouldn't want your family faced with the unexpected trauma of the possibility of you dying to have no idea what your wishes might be. I am in my early 40s and had these discussions with family members over a decade ago. I hope very much they will be theoretical discussions for decades to come but would rather my family were prepared if some thing awful and unexpected happened.
Flying we do it because some times it works and when the patient is already dead you have little to lose. But, and this is a big but most of the time it doesn't work and it is brutal and undignified so if you know in advance that it won't work (which is what we are talking about with a DNACPR order) then a calm and dignified death is better. One of the big problems for HCP's is programmes like Holby City, ER and Casualty that show CPR as a couple of minutes of compressions and a couple of shocks nearly always having a positive outcome. It just isn't the reality most of the time unfortunately.

Princess We have already talked about it, I just meant the formal written DNACPR which isn't necessary yet. I am going to get enduring power of attorney (both types) set up so it can slot into place should I become incapacitated.
In my job I see too many people where disability strikes out of the blue to want to leave things to chance. Fortunately we are a fairly open family where these things are discussed with relative ease.
I wholeheartedly agree with you about the Holby City effect, to have relatives shouting at you asking why you are not shocking their family member is heart breaking and I think much more widespread teaching of CPR would help with this.