DNR discussions
I would like to pose a scenario
A lady of over 90 who has dementia. She is very frail but happy in her own way.
The GP was contacted as she had a bit of a cough. The receptionist took details to be passed on to the doctor. When the GP called it was to triage to see if mum needed a home visit. During the conversation they asked if a hospital admission was being requested, this was refused. The GP then asked if there had been a conversation about resuscitation. This seemed quite shocking as it didn't seem the time to be discussing this. The practice manager said this is normal protocol and the doctor would have discussed it when they came to visit. The conversation would have been carried out in front of mum. Fortunately it was a practice nurse who came out and diagnosed a chest infection. She was asked about DNR and she said it was something to consider and it was discussed. She did actually say she felt uncomfortable talking about it in front of mum however mum is hard of hearing so she was told not to worry. She showed sensitivity and compassion which appeared to be lacking in the GP. Mum has been in hospital several times this year and it has never been mentioned.
Is it appropriate in the circumstances outlined above to be asked this question out of the blue in such a matter of fact way.
The practice manager is correct in saying that it is normal protocol to raise the question around DNAR.This ensures that an individual's personal preferences or that of their family are both respected and supported. Very often this question is asked for example on admittance to a care home or hospital. For most people it is a difficult question to ask, and equally is a difficult question to have to answer. But speaking from personal experience it is better to deal with it in advance rather than at a time when the decision determines the outcome. But it is a subject that should always be dealt with in a respectful and compassionate manner.
My mother has vascular dementia and on many occasions has refused to visit the doctor, luckily our surgery is familiar with Mother and after 4 days , and her chest becoming quite serious they decided on a home visit. No one has ever talked about DNAR to myself or my daughter ,who is her main carer.
Hi Liz,
This is something which is both complex and 'fraught', and very-much depends on 'where you are standing'.
There has in the past been far too much decision-making about DNACPR performed by doctors in hospitals, and 'too late in the day' for adequate discussion. So, there has been - correctly in my opinion - a recent push for GPs to try and elicit the views of elderly patients, about whether or not they would want CPR to be attempted. As DiC readers might be aware, I write endlessly about the process and law around 'consent to intervention'.
There is a lot wrapped up in the first sentence:
'A lady of over 90 who has dementia. She is very frail but happy in her own way.'
If for a moment we assumed a patient who was very frail but did NOT have dementia, the situation is that if the doctors are certain that the existing frailty would mean that future attempted CPR could not re-start the heart, they are not required to 'offer' CPR. But our judges have made it clear that in this situation, the patient should normally be told by the doctors, that the clinicians do not intend to attempt CPR. In reality, doctors can almost never be 100% certain that future CPR could never re-start the heart - so, my position is basically that if doctors say 'it couldn't work' but a capacitous patient says 'I want you to try anyway', then CPR should be attempted.
Such a capacitous patient can [in theory if not necessarily in reality] forbid attempted CPR, however likely it is that CPR would be clinically successful.
It is trickier - much trickier - if the patient is living with dementia, and cannot make her own decision about CPR, if there is a possibility that CPR might be clinically successful. In that situation, the murky process of MCA Best-Interests Decision-Making should be embarked upon: usually there will not be any individual with legal authority over best interests (many clinicians claim that the senior clinician possesses that legal authority - I claim they are wrong about that: only section 6(6) of the MCA gives 'legal authority' over best-interests) which would involve discussions between the clinicians and the people who know the patient as an individual. It isn't easy to describe best-interests decision-making, but it would involve things you hinted at in your sentence: what would the likely clinical situation after an arrest and 'successful CPR' be, and would the patient 'be happy to be alive in that situation'. Clearly [to me, at least], if we assumed the best-case outcome - that she would be clinically-identical to her situation before the arrest - the decision should be 'then we attempt CPR' because you say [and this might be disputed during the best-interests discussions, but here I am assuming it is agreed] 'She is ... but happy in her own way'.
If it is believed that there is no possibility of CPR being clinically successful, so it will not be attempted, and the patient is living with very severe dementia, then there is the question of 'should she be informed': in that situation I think it is hard to see any advantage to the patient in being told (even if she could understand what CPR is), so it seems reasonable to inform the family - and 'family carers' do NEED to know! - but not the patient.
Hope I've not made too many typos in that, and I could have written on - I will post the question on Twitter [several doctors and senior nurses 'follow me' on Twitter] and I'll see if that attracts any replies.
If you make an advanced decision and this is correctly recorded to have resuscitation attempted then its not up to the clinician or care staff. They will attempt resuscitation as per your treatment wishes. If you decide not to they wont.
Certainly in a care home where end of life is a consideration they really have to ask as this avoids issues later when the issues arises for real and staff on the spot and ambulance crews. DNAR is treatment like any other treatment the individual has the right of consent or not. Families and Friends do not have the right to dictate treatment regardless, its the individuals decision. The Care Organisation should discuss the issue with the family but they cannot make the decision.
When a individuals capacity may be in question it is important especially in the case of Dementia as capacity will only decrease as the disease progresses this must be discussed at the earliest opportunity to ensure the individuals wishes are respected. Once it is too late and it is felt the individual has no longer capacity it will be the medical team making this decision, they may take in to consideration family views but it is up to them.
I would like to think that every family member has their loved ones interest at heart but sadly this is not true, therefore the Care team must have some firm evidence that a DNAR is wished otherwise implied consent applies.
Please, Please, Please put in a properly considered advanced decision in place in consultation with your care team as early as possible. If you can I must encourage a Power of Attorney Health and Social be in place that becomes enforceable when capacity is lost. I would advise everyone over 70 to have one with a loved one they can trust.
All concerned must ensure they do not confuse ADRT with DNACPR; they are two completely different 'DECISIONS'. Having a DNACPR does not include ADRT whereas, having an ADRT, does include a DNACPR.
Suzie Lloyd
Yes Liz it seems cold and not the correct time to ask about CPR ! DNA . Our mum had dementia and was usually happy and chatty . When she went into a care home 3 years ago she had several falls and chest problems during the last year of her live. My brother and all of the rest of the family and including mum we sat and discussed what we all wanted where DNR was concerned . Mum was not to far into the dementia and explained that she wanted a DNR put into place ..Mums words where if I am that bad leave me alone . So we got all the legal documents. Filled out and we have all put our wishes into place . Mum did not need CPR and came through both operations no problems . Now. Mum has passed away and I feel she enjoyed her live. So yes the practice was correct to ask but I feel that these types of desisions should be made when we are well.
DiC has moved this question over to the Dignity in Action Facebook page - it is being discussed quite actively, over there.