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Five steps to writing safe Do Not Attempt Resuscitation (DNAR) requests

Dr Zaid Al-Najjar gives advice on five steps to creating a watertight policy for Do Not Attempt Resuscitation (DNAR) requests, and shares a key case study

Mrs E is 89, lives in a local nursing home, and suffers from chronic heart failure.

Your GP registrar asked for the cardiac specialist nurse to visit her recently and the nurse informed that her heart failure is now end stage.

The nursing home calls you while you are the duty doctor and asks for a ‘Do Not Attempt Resuscitation’ (DNAR) form to be completed, in light of the nurse’s findings. They ask for you to visit this afternoon, as she is deteriorating rapidly and they are concerned about her having an undignified death.

You are conscious of the recent media coverage about the Liverpool Care Pathway and are worried about the consequences of filling out the form. However, you are also aware of how distressing CPR can be and how futile it appears in so many cases when no firm decision has been made by the clinical team to complete a DNAR form.

In the community, the chances of surviving a successful cardiopulmonary resuscitation are thought to be as low as 5-10% - even lower than in hospital. Such procedures are very often traumatic, causing rib fractures, not to mention damage to internal organs, including the brain.

You visit Mrs E, examine her and talk to the staff. You decide she doesn’t have capacity to make her own decisions and that she seems very frail. Her daughter feels very strongly that she should be resuscitated should she take a turn for the worse. You are uncomfortable about this think and think that resuscitation would not be effective. The relevant guidance suggests that if CPR would not restart the heart, then it should not be attempted, so you decide a DNAR form would be appropriate to complete.

Research has 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.

However, the fact that you have discussed this case with Mrs E’s daughter seems to have made this more complicated. You discuss your dilemma with your partners at work and with the Cardiac Nurse Specialist who all agree that it is unlikely that CPR would be in Mrs E’s best interest and there is no evidence that she would have wanted it.

You invite Mrs E’s daughter to come into the practice to discuss your decision to complete a DNAR form. She comes in with her brother who agrees that Mrs E should not be given CPR, should the need arise. After reassuring Mrs E’s children that this does not mean that you would not actively treat her and that it would simply mean allowing her to die a dignified death, without the traumatic experience of CPR, the daughter seems to understand somewhat and agrees. Mrs E has no other family members or close friends besides the two children.

You complete the DNAR order and speak to the nurse in charge. You ask her to make sure that this is handed over to the rest of the healthcare team and that the DNAR form is kept clear in the nursing record, so that any member of the nursing team would see it, should they look at the notes.

Mrs deteriorates and dies a week later, and you receive a complaint after a month from her daughter. She is unhappy and distressed with the fact that you decided against the option of CPR, as she feels it could have saved her mother. You are very glad that you recorded the detail of your discussions and documented your reasons for deciding on the DNAR given that Mrs E lacked capacity. You are relieved that you didn’t agree to complete a DNAR quickly under pressure from the staff in the nursing home and feel confident in composing a response to the complaint from a grieving relative.

This case study shows how responding to a DNAR request can raise a number of issues and it is not always straightforward. The BMA, Royal College of Nursing and Resuscitation Council have produced joint guidance about making decisions. The GMC also provides advice to clinicians: ‘If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful, making and recording an advance decision not to attempt CPR will help to ensure that the patient dies in a dignified and peaceful manner. It may also help to ensure that the patient’s last hours or days are spent in their preferred place of care by, for example, avoiding emergency admission from a community setting to hospital.

’Some patients with capacity to make their own decisions may wish to refuse CPR; or in the case of patients who lack capacity it may be judged that attempting CPR would not be of overall benefit to them. However, it can be difficult to establish the patient’s wishes or to get relevant information about their underlying condition to make a considered judgement.’

Following the five steps below can help you create a watertight policy for agreeing to write a DNAR request for a patient.

1 Consider the options

Is CPR likely to be successful? If it is not then consider the wishes of the patient, if they have capacity to make their own decision. If the patient does not, check whether they have ever given any indication of their wishes on the subject.

2 Discuss decisions

Talk to the rest of the healthcare/multi-disciplinary team and with the next of kin/family/close friends (or legal proxy) and find out what they think. Ensure that they are aware of the decision made and why it was made. If the person lacks capacity and has no family or close friends or legal proxy then take further advice from your medical defence organisation about the way forward.

3 Record discussions

Ensure you record any discussions in the medical records clearly, along with the reasons for the decisions made. Consider that any such decisions can be reversed, should it become apparent that the patient’s situation changes and that it is felt that CPR may be successful.

4 Reassure relatives

Reassure worried family and friends that a DNAR order does not mean that they are going to miss out on active treatment. Provide information on what the decision will mean. Good communication is vital to build and maintain a good doctor-patient relationship and can help prevent complaints.

5 Inform clinicians and carers

Make sure that the immediate care/nursing staff are aware of the DNAR order and that it is visible and immediately apparent to anyone accessing the medical/nursing records. Should there continue to be disagreement about the DNAR order then seek further advice from your medical defence organisation.

Dr Zaid Al-Najjar is a medico-legal advisor at the Medical Protection Society (MPS) and a practising GP in London.

Readers' comments (5)

  • Most of the time when you visit a patient in a nursing/residential home, there is no family members available to discuss DNACPR with. I have had to withdraw a signed form when a patient's son who lives in a foreign country refused to acknowledge it despite my offering to discuss it on the phone with the relatives. The patient lacked capacity and I discussed it thoroughly with the home manager and we felt it would be in patients best interest to have a DNACPR form in placed.

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  • DNR/DNAR/DNACPR - whatever the abbreviation, phrases involving 'do not resuscitate' throw up lots of emotions and sometimes barriers for patients, relatives and hcp's. This of cause has been further heightened with the media's negative portrayal of the Liverpool Care Pathway. In this situation we have now changed our practice and talk about 'Allowing a natural death', what this would mean for the patient and how attempts at CPR would be futile and not allow the natural peaceful death that we had previously been explaining about. The paper work has also been re-named 'Allow a Natural Death'. I've found it a much gentler way to introduce the topic to patients and much earlier.

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  • Let common sense prevail

    This case discussion is interesting, and indeed a very realistic scenario that happens frequently. Unfortunately what it illustrates to me is that an enormous amount of clinical time and effort has been used to achieve absolutely nothing other than a complaint. This illustrates much of what is wrong about our current approach to medicine.

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  • David ,
    you are absolutely correct

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  • David
    It also achieved a dignified and peaceful death for the patient.

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