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Debating DNAR orders

We have received a number of letters from readers about this article, in particular the statement: “If, after careful consideration, clinical evidence suggests that it is not in the patient’s best interests to perform CPR should it be needed, this must be discussed fully with the patient.”

We accept the criticisms raised that the use of the phrase “must be discussed” is incorrect and does not apply to every clinical situation.

The purpose of the article was to emphasise the need for good communication in this area, given the rising number of complaints about DNACPR decisions being made without the knowledge of patients or their families, and the generally accepted best practice approach of involving patients in decisions about their care (“no decision about me, without me”).

The purpose of the article was to emphasise the need for good communication in this area, given the rising number of complaints about DNACPR decisions being made

However, there are situations where clinical judgment will determine that such discussions are not appropriate, or timely – for example, in the case of the dying patient.

For clarification we set out below the relevant section from the GMC guidance Treatment and Care towards the End of Life: Good Practice in Decision Making, which states:

134. “If a patient is at foreseeable risk of cardiac or respiratory arrest and you judge that CPR should not be attempted, because it will not be successful in restarting the patient’s heart and breathing and restoring circulation, you must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made. You should not make assumptions about a patient’s wishes, but should explore in a sensitive way how willing they might be to know about a DNACPR decision. While some patients may want to be told, others may find discussion about interventions that would not be clinically appropriate, burdensome and of little or no value. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.”

Guidance published by the BMA/RCN/Resuscitation Council in 2007 on this issue also states: “In considering this clinicians need to take account of the fact that patients are legally entitled to see and have a copy of their health records, so it may be preferable for them to be informed of the existence of a DNAR decision and have it explained to them rather than for them to find it by chance. It may be distressing for them to find out by chance that a DNAR decision has been made without them being involved in the decision or being informed of it.”

Clinicians need to take account of the fact that patients are legally entitled to see and have a copy of their health records, so it may be preferable for them to be informed of the existence of a DNAR decision and have it explained to them

The guidance goes on to advise doctors to record the reasons why a patient has not been informed about a DNACPR order if the decision is made not to inform the patient. We are pleased to respond to the concerns raised by readers, and welcome all feedback.

With regards to “Debating DNAR orders” (Casebook 20(1)), the comment from Dr Davies, your adviser, was appropriate – the real issue is whether comprehensive discussion of management options has taken place.

Unfortunately, the medical profession has been guilty of placing almost all the emphasis on the isolated issue of cardio pulmonary resuscitation, which, of course, is an entirely inappropriate form of management for the majority of patients dying from progressive illness in medical wards up and down the country.

The relevant discussion is about “ceiling of treatment” – what treatment approaches are and are not appropriate for a given clinical picture. Thus, for example, if intensive care management would not be appropriate for a patient with progressive respiratory failure, CPR would automatically be inappropriate.

As a patient’s clinical state deteriorates it often becomes obvious when DNAR is appropriate and in reality not something that is a realistic discussion

The discussion of do not resuscitate orders at a relatively early stage in a progressive illness inevitably risks concerns for patient or family about the approach to overall care. It also raised a genuine difficulty in distinguishing an acute unexpected event from progression of the underlying disease. As a patient’s clinical state deteriorates it often becomes obvious when DNAR is appropriate and in reality not something that is a realistic discussion.

The resuscitation issue lies between these points, when it is apparent that a clinical picture is deteriorating and possible management options such as treatment change or involvement of intensive care need to be considered. At this juncture the focus of discussion should be on these management options with the issue of DNAR being a secondary consequence from this discussion.

There will, of course, be the occasional patient with a chronic illness who does not want CPR under any circumstance. We should be sensitive enough to pick up on that. However, those cases are an exception.

Duncan Macintyre
Consultant physician in respiratory medicine, Scotland

This disagreement has been publicly discussed for many years, and screams “communication failure” between hospital staff and patients, and their relatives – particularly their relatives. But also, sadly, between hospital workers and the president of the Royal College of GPs.

Resuscitation is not for patients to opt in or opt out, like breast enhancement or a facelift. It is the dramatic last stand in a provision of circulatory and respiratory support offered to some patients. Patients can choose to refuse any treatment at any time, but appreciation of medical limits increases confidence and trust.

Patients need to understand that when all definitive treatment for a disease has failed, and the circulation ceases, this is not the time to start treating the disease, because everything possible has already been done

About 50 years ago DNR (Do Not Resuscitate) labels were placed on some patients’ notes by doctors to stop the cardiac arrest team being called out for every death. The team, called to treat an unfamiliar patient, would have to read the notes in detail, by which time the treatment would be too late. This precaution allowed the nurses to avoid mistakes that would waste valuable staff time and energy, valuable blood and expensive disposable equipment and materials.

Patients need to understand that when all definitive treatment for a disease has failed, and the circulation ceases, this is not the time to start treating the disease, because everything possible has already been done. If it is known that the cause of death cannot be reversed, nothing more can be achieved. This should be the basis for any discussion, if discussion is sought.

There are a few circumstances in which it may be reversed, when the lethal blow was so sudden that earlier support could not be given, then it may be possible to help a patient whose heart has stopped; including coronary occlusion, electric shock, embolism, suffocation, drowning, haemorrhage, hypothermia, poisoning (including gas), severe head or chest injury and a few other recent insults.

Explaining to a patient that resuscitation is “not in your best interests” will not soothe a suspicious patient; it will make him very cross!

Dr CJF Potter
Retired, UK

“Just a quick look” can be costly

As a recently graduated doctor, I read “’Just a quick look’ can be costly” (Casebook 20(1), p19) with interest. Despite my relative inexperience, I am frequently asked to review other hospital staff who drop into my ward ‘as a favour’. My initial instinct is to accommodate such requests out of a sense of professional courtesy and fear of being labelled a jobsworth should I decline. After all, we are all very busy people working to help others and taking a quick look for a colleague very often seems like the right thing to do.

I am increasingly concerned that such behaviour represents neither best practice nor a good use of NHS time and resources

However, I am increasingly concerned that such behaviour represents neither best practice nor a good use of NHS time and resources. Requests for advice or review are rarely accompanied by paperwork highlighting past medical history, allergies or current medications and there is no pathway in place to allow for vital communication back to the individual’s GP.

Additionally the pressure to arrive at a quick decision often leaves minimal time to take a history and form a considered diagnosis. Since recently starting a new rotation, I have found the problem to be more of an issue in otolaryngology, perhaps as examination often necessitates more specialist equipment often not found on other wards.

Although I am becoming more proficient in many ENT investigations and procedures, diagnoses are not always the most obvious or easily formulated, which can lead to disappointment, uncertainty or even anxiety. Worryingly neither my department nor hospital has a defined policy of how to handle these cases of "quick looks".

I have come across areas where such impromptu consultations are tacitly encouraged if they reduce time taken off work

The GMC stipulates that contemporaneous notes should be kept in keeping with good medical practice but offers little other advice. Although my trust has no guidelines on the subject and seems to take a neutral attitude to the issue, I have come across areas where such impromptu consultations are tacitly encouraged if they reduce time taken off work.

Given the potential medicolegal pitfalls and consequences highlighted when dealing with such cases, I feel I would benefit from greater guidance either from individual hospital trusts or the GMC on how to manage such cases, so that I am able to alleviate and reduce any anxiety both for me or my unsolicited patients.

Timothy Batten
Junior doctor, UK

Double problem, double risk

The report on the patient with tonsillar cancer surprises me; it is hard to believe that an ENT surgeon consulted about “a recurrent sinus problem” does not perform a full ear nose and throat examination, or at the very least an inspection of the oral cavity and pharynx. To read that the patient mentioned “ongoing ... sore throat” and that the ENT surgeon suggested that the patient get his GP to check it reflects professional laziness or incompetence on the part of the specialist.

If indeed the specialist did examine the throat, it seems likely that it was not a competent examination, as within a month there was an obvious tonsillar carcinoma evident on inspection, and accompanying metastases in the cervical nodes.

It is hard to believe that an ENT surgeon consulted about “a recurrent sinus problem” does not perform a full ear nose and throat examination

I am also surprised that the learning points did not conclude that the initial ENT assessment was inadequate, and that the specialist’s response to the patient’s expressed concern about his throat was unacceptable. At the very least the specialist should have examined the throat in the light of the information provided.

Given the findings one month later, an adequate initial specialist assessment, in all probability, should have raised the alarm at that time.

Randall Morton
Professor of otolaryngology – head and neck surgery, University of Auckland, New Zealand

Response

The points you make about the consultation are very valid, and it is only a limitation on space that means we are unable to include all of the learning points from every case. The focus of this case report was to highlight the need for vigilance when patients present with more than one complaint, but there were clearly other issues of concern, as you have pointed out, that led to this claim being settled. Thank you for taking the time to share your views on this article with us.

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