Dr Jonny Morris describes a tricky scenario of a patient with a do not attempt resuscitation (DNAR) order.
DNAR orders are frequently found in patients’ notes within a hospital setting, and occasionally in the community. They are used when it is thought that performing cardiopulmonary resuscitation (CPR) on a patient who has a cardiorespiratory arrest would not restart the heart and maintain breathing, or when the patient themselves has expressed a wish not to have CPR.
The decision as to when a DNAR order is appropriate is usually made by the most senior clinician involved in that patient’s care. However, as junior doctors we often gain a good impression of our patients’ comorbidities, functional state and quality of life, and so may play a key role in these decisions. DNAR orders can be controversial and often pose significant ethical and legal dilemmas for medical staff, patients and families as reflected in this tricky hypothetical scenario.
The medical team
Mrs F, an 82-year-old, presented to the hospital with worsening shortness of breath. She was very frail with multiple cardiorespiratory co-morbidities and significant cognitive impairment, secondary to end-stage Alzheimer’s disease. She was started on treatment for decompensated heart failure before being transferred to our ward. She was reviewed later that day by my consultant, who felt that a DNAR order would be appropriate. The impression of the medical team was that her medical comorbidities and frailty would make any CPR attempt futile and would not be in her best interests.
The patient
A careful assessment was undertaken to decide whether she had the capacity to contribute towards this important decision. We also tried to explore her wishes for her continuing care. Ultimately, it was felt that she did not have capacity with respect to the DNAR decision. A DNAR order was completed and signed by the consultant.
We attempted to contact her family to gain a better understanding of Mrs F’s background and to discuss the DNAR order. Unfortunately, there were no contact details in the patient’s notes, she was unable to provide any information, and she had not had any visitors to the ward.
The family
The next morning, Mrs F’s family arrived and asked to talk to the medical team. Her heart failure was not responding to medical management as we had hoped and she had deteriorated significantly overnight. The family were very upset that a DNAR order had been put in place and expressed their wishes for Mrs F to receive all possible interventions in the event of a cardiac arrest.
My consultant explained to the relatives that due to her multiple medical problems and current acute illness that CPR was unlikely to be successful and would be very traumatic, but the family still insisted that they would like resuscitation to occur. Despite lengthy discussions the family remained opposed to the DNAR order, while our team’s impression was that resuscitation was not appropriate
A difference of opinions
As doctors we strive to do what is best for our patients, ideally incorporating their own wishes and working closely with their loved ones. We empathise with the family, who are facing the death of a close family member, and may feel that important decisions have been taken out of their hands by people who do not know their relative. The family, understandably hold every hope that their relative might recover and want them to have every chance. But how do you proceed when the views of the family conflict with those of the medical team?
"If a patient has capacity they should be offered an opportunity to discuss the benefits and burdens of CPR"
Medicolegal advice
By Dr Jo Galvin, MPS medicolegal adviser
Decisions regarding cardiopulmonary resuscitation (CPR) are challenging for all those involved in patient care. Patients and relatives may be concerned that agreeing to a decision not to resuscitate may mean that the patient will not receive the care that they require.
If a patient has capacity they should be offered an opportunity to discuss the benefits and burdens of CPR. Such discussions need to be approached sensitively exploring any concerns the patient may have and explaining clearly and in non-medical terms what CPR involves, the associated risks and possible sequelae, even if CPR is successful. It is important to explain the reason(s) why CPR is considered not to be clinically beneficial in their case.1
Some patients may still wish to receive CPR even if there is only a limited chance of success. The GMC advises in these circumstances you should explore the reasons for the patient’s request and try to reach an agreement. It may be possible to agree to limited intervention in some circumstances. If the risks and benefits of CPR are finely balanced then the patient’s request is likely to be the deciding factor.
If in the doctor’s opinion the risks outweigh the benefits and the patient requests CPR, you are not obliged to agree. It is important to explain the reason(s) for your decision and to offer the patient a second opinion.
When a patient lacks capacity it is essential to establish:2
(a) If the patient has appointed a legal deputy (Personal Welfare Power of Attorney) who has the authority to make such a decision.3
(b) If there is a valid and applicable Advance Directive.4
If neither of these provisions is in place you must discuss the issue with those close to the patient and with the wider healthcare team. It is important that those whom you consult are made aware that the overall responsibility for the decision rests with the clinical team and that their input is to assist in the decision making.5
It is also important that all discussions regarding CPR are carefully and contemporaneously documented in the patient’s records.
"It is important that all discussions regarding CPR are carefully and contemporaneously documented in the patient’s records"
If following a detailed discussion the matter remains unresolved, it may be worth considering the following options:
- Involving an Independent Mental Capacity Advocate (IMCA).
- Seeking advice from a more experienced colleague or seeking a second opinion.
- Considering a multidisciplinary case conference.
- Involving local mediation services.
If the situation remains unresolved it is advisable to seek legal advice as recourse to the courts may be necessary. The patients or those involved in the decision making process should be informed as soon as possible of this step so they have an adequate opportunity to prepare and be represented.
References
- GMC, Treatment and care towards the end of life: good practice in decision making, (May 2010)
- Mental Capacity Act, Code of Practice (2005), pg 123 para 7.30: “An attorney can only consent to or refuse life-sustaining treatment on behalf of the donor if, when making the LPA, the donor has specifically stated…that they want the attorney to have this authority.”
- Ibid no 2 at page 166 paragraph 9.24
- Ibid 1, pg 65 par 140
- Ibid 2, pg 179 par 10.1