7 Debating DNAR orders


When a patient suffers a sudden cardiac or respiratory arrest, cardiopulmonary resuscitation (CPR) is often attempted, with presumed patient consent unless explicitly stated otherwise. Sarah Whitehouse asks: should CPR be opt in or opt out?


I


ona Heath, President of the Royal College of General Practitioners, argues opt in: “The default position


for most medical interventions is that patients have to opt in by giving informed consent for the procedure. Why should this not be the position for CPR?”1


Those


already in poor health might be better able to have a realistic assessment of their chances of survival, while those in previous good health would be able to opt in without hesitation. Television hospital dramas give the


impression that CPR attempts are usually successful; in fact, the reality is different. After a CPR attempt that takes place in hospital, the chances of surviving to hospital discharge are around 15-20%. Outside hospital, the chances of survival are even lower, at 5-10%.2


Efforts to


restart the heart are traumatic and often cause rib fractures and damage to internal organs. Lack of oxygen can lead to hypoxic brain damage or coma; and, if efforts are unsuccessful, a potentially undignified death. The GMC’s guidance on end-of-life


care starts with the premise: “Patients who are approaching the end of their life need high-quality treatment and care that support them to live as well as possible until they die, and to die with dignity.”3


There is a dichotomy


between this ideal of a dignified death and the often traumatic reality of CPR. Decisions relating to cardiopulmonary


resuscitation, issued jointly by the BMA, Resuscitation Council and Royal College of Nursing, states: “Where no explicit decision has been made in advance, there should be an initial presumption in favour of CPR.”4


In an


emergency, the focus is the preservation of life, and to have a policy other than opt out would be to go against this principle. However, it is not appropriate to prolong life at all costs, with no regard to its quality or to the potential burdens of treatment for the patient.5


FURTHER READING:


■ GMC, Treatment and Care Towards the End of Life, www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp


■ Liverpool Care Pathway for the Dying Patient, www.liv.ac.uk/mcpcil/liverpool-care-pathway


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 (or their family if they do not have capacity). Doctors must carry out a thorough assessment of the patient’s condition and consider the likely prognosis, based on the “overall benefit” to the patient. Any decision must be recorded and reviewed regularly.


to zero”.9 However, patients cannot


demand a particular course of treatment if clinical evidence suggests it would not be in their best interests. If a patient refuses CPR, or a patient


lacking capacity has a valid and applicable advance decision refusing CPR, this decision should be respected in accordance with the Mental Capacity Act 2005. Patients go to great lengths to make sure that their wishes are known. In a bizarre case, an 81-year-old woman,


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


Sometimes, however, doctors place


Do Not Attempt Resuscitation (DNAR) orders in a patient’s notes without discussion. Recently, Janet Tracey, a 63-year-old care manager, died in hospital following a car accident. Doctors placed a DNAR order on her notes – which her family claim was done without their knowledge. Her husband is suing the Health Secretary in a bid to force the government to draw up a national, rather than local, DNAR policy.6 Yuen et al have identified two major


problems with DNAR orders: firstly, DNAR discussions do not occur frequently enough; and secondly, these discussions occur too late in the course of patients’ illnesses to allow their participation in resuscitation decisions.7 There is also the perceived problem amongst patients of a “DNR creep”; the assumption that if patients do not want to be resuscitated, then they do not want any other form of life saving treatment.8 Roger Goss, co-director of Patient


Concern, says that although doctors argue that CPR offers some patients a poor chance of survival, refusing it when patients want it “reduces it


Joy Tomkins, from Norfolk has had “Do Not Resuscitate” tattooed across her chest and P.T.O. across her back. CPR, in the right circumstances,


can be of benefit to a patient in an emergency, but for those who are seriously ill and at the end of their life, it may not be the most clinically appropriate, or dignified, choice. Dr Marika Davies, MPS Medicolegal


Adviser, says: “The crux of the issue is not whether CPR should be opt in or opt out, but whether the discussions between seriously ill patients, their families, and the doctors who care for them are comprehensive enough to address the clinical appropriateness of CPR and decide on a mutually agreed treatment plan.”


REFERENCES


1. Heath, I, Opt in not out: Why is patients’ consent presumed for cardiopulmonary resuscitation? BMJ 343:5251 (2011)


2. British Medical Association (BMA), Resuscitation Council and the Royal College of Nursing (RCN), Decisions Relating to Cardiopulmonary Resuscitation p6 (2007)


3. GMC, Treatment and Care Towards the End of Life p8 (2010)


4. BMA, Resuscitation Council and RCN, Decisions Relating to Cardiopulmonary Resuscitation p3 (2007)


5. Ibid p3 6. Husband’s battle to re-draw ‘do not resuscitate’ rules after wife dies in hospital blunder, Daily Mail (31 August 2011)


7. Yuen JK et al, Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them, JGIM 26:7 (2011)


8. Truog, RD, Do-not-resuscitate orders in evolution: Matching medical interventions with patient goals, Crit Care Med 39:5 (2011)


9. www.patientconcern.org.uk


ARTICLE


UNITED KINGDOM CASEBOOK | VOLUME 20 | ISSUE 1 | JANUARY 2012 www.mps.org.uk


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