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Last year the Resuscitation Council (UK) together with the British Medical Association and the Royal College of Nursing updated their statement “Decisions relating to cardiopulmonary resuscitation”. This short document should be read by all healthcare professionals whose practice may involve “do not resuscitate” (DNR) decisions. It is designed to be a framework on which hospital and other trusts may build their own more detailed guidelines.
The advice contained within the document seems simple enough. There are three situations in which a DNR order is appropriate: if cardiopulmonary resuscitation (CPR) is unlikely to be effective; if it is known that the patient does not wish to receive CPR; and if successful CPR would not result in a length, or more importantly a quality, of life which would be in the patient's best interest.
Surely few would disagree? Yet there has been considerable misunderstanding, particularly on the part of the public, and some reluctance by the medical profession to follow these guiding principles.
Maintaining other treatment
It must be fully understood by all concerned—patients, doctors, nurses, and relatives—that DNR orders apply only to the decision whether or not to initiate CPR in the event of respiratory or cardiac arrest. Unfortunately, there is, at least in the USA, evidence that this principle is not always adhered to.1 A DNR order should not in any way limit other medical or nursing care that the patient receives; best practice and patient confidence demands that we all openly subscribe to this principle. It is equally important that consultants (or their equivalents) do not shy away from their responsibility to introduce appropriate DNR orders for fear that other treatment may be withdrawn from their patients. Instead, they should ensure that their trainees are fully aware of the need to continue all other appropriate therapeutic management.
When is resuscitation inappropriate?
The end of life is always marked by cardiopulmonary arrest. Thus, CPR could be attempted whenever death occurs. But CPR is at best traumatic and often invasive. To insist that it should be administered when there is no reasonable hope of success is to deprive a human being of a dignified death. Those who have come to the end of their natural lives should be allowed to die as peacefully as possible. Because the techniques of CPR are available, nursing staff are mostly under a professional and managerial obligation to initiate the process unless specifically instructed otherwise. This requires a DNR order, which should be made whenever death can be anticipated and resuscitation judged pointless.
Responsibility for a DNR order
A letter from the chief medical officer (PL/CMO(91)22) makes it clear that the responsibility for making a DNR order is that of the consultant (or equivalent) in charge of the case. As with other forms of patient management this responsibility may have to be delegated to the next most senior doctor on duty, particularly if the need for a decision arises before the consultant has seen a newly admitted patient. But, like any other decision taken by a trainee doctor, the ultimate responsibility remains with the consultant and should be confirmed by him or her at the first possible opportunity. The best time for such decisions to be taken is on the post-take ward round. This should allow time and opportunity for full discussion with other members of the healthcare team, the patient, and relatives. By discussing the matter then it is hoped that the scenario of a very junior doctor being asked for a decision in the middle of the night can be avoided.
Should the patient be involved?
Patients should always be kept informed of the progress of their disease. Relatives often suffer as much as the patient, at least emotionally, and should also be kept up to date and given the opportunity to ask questions, always within the bounds of medical confidentiality. When the prognosis is poor, particularly if death is imminent, it requires sensitivity to fulfill these obligations.
The patient's decision
It is important that if a DNR order is being considered, and the patient is capable of a competent reply, he or she is asked for a personal decision. This should be the norm. It is not an easy or pleasant task to carry out, and training is needed in the same way as it is for other clinical skills.
A patient has the right to refuse a specific treatment but not to insist on it. Thus, refusal of CPR is legally valid, but a demand for it is not. In the UK there is currently no legislation covering advance statements. However, the outcome of legal cases has shown that a valid applicable advance directive, that relates to the patient's current clinical circumstances, is legally binding on doctors.
When a patient is not capable of expressing an opinion—for example, if unconscious—the decision for or against CPR must be made by the doctor looking after the patient, the ultimate responsibility being that of the consultant. Other medical and nursing staff should be involved, and the views of relatives or close friends should be sought in an attempt to gain insight into the wishes of the patient. Such discussion with relatives helps to improve communication and keeps those who care for the patient fully informed. But it must be understood that no relative has a legal right to determine an adult patient's treatment. On a pragmatic note, however, when a patient dies it is the relatives who are left to complain. There is no doubt that this is much more likely to happen if communication has been poor.
Should questioning about resuscitation become routine?
Patients presenting to a doctor or hospital may reasonably be considered to have implied their desire to be kept alive. Most doctors would find routine questioning about CPR unnecessary and even unkind, evoking the reaction, “Do you expect me to die then?” However, if public confidence in the integrity of the medical profession does not improve, such questions may well become mandatory with each and every patient who enters hospital being required to sign a consent form for or against CPR. Perhaps good could come out of this by asking at the same time for permission for organ donation.
It would be interesting to know whether “real” patients would welcome this; so far we have heard mainly from the vociferous minority with an axe to grind or a political agenda.