Cardio-pulmonary resuscitation (CPR) will be administered to patients in cardiac or respiratory arrest for the purpose of prolonging their life. Its simply that, to prolong life while other options are considered – or more likely attempted to correct an underlying cardio pulmonary fault. CPR can encompass often violent chest compression’s which can cause bruising and even fracture of ribs. The treatment also includes attempts to ventilate lungs, defibrillation with electric therapy and injection of medications and stimulants. It is important to recognise that CPR is not a 100% successful tool for life preservation even in the short term, the average success rate tends to hover in the region of around 20% and that figure decreases substantially for attempts at CPR in emergency paramedic or community environments without additional services and equipment available in a Hospital setting.
The patients underlying medical cause for cardio / respiratory distress is important as a factor in the eventual resuscitation success rate. It is also important to recognise that the process is one where permanent brain damage can occur even if the heart is restarted. IN every case, a patient who is resuscitated will need a prolonged stay in ICU and that will in most cases see a recurrence of the distress unless there is a rapid reversal of those underlying symptoms. The provision of CPR is not a entitlement, it is always a balanced decision by the clinicians with care, it is only ever attempted if it is not futile.
Whilst is it is difficult to reconcile, a DNR is not a family choice it is the choice of the treating clinician. Ultimately the family should be consulted and informed and not doing so is a breach of duty however, the family can object but cannot insist upon its reversal.
What is a DNR – DNAR order? DNR – Do Not Resuscitate also known as DNAR (Do not attempt resuscitate orders). This is a legal order which can inform a medical team not to perform CPR on a patient. The order is usually made by a clinician with reference to the family but need not be consented by the family. However this order, does not affect other medical treatments. It is not a “do not treat me order”. Further terminology has been suggested “A.N.D” which stands for Allow Natural Death. This is much more likely to provoke the right sentiment in the public. DNR makes it sound as though something is being denied. Ultimately, at the point of a CPR attempt, the patient is already substantially damaged and unlikely to be revived.
What is the purpose of a DNR?A DNR provides legal written evidence of a patient’s or patients families wishes that can be used to guide the appropriate course of action taken by a medical team. CPR decisions are as already indicated a balanced way forward, there is a great deal of highly experienced clinical talent in the room for these decisions and often the family nor the individual thank the team for bringing round a patient who then has to suffer substantial and debilitating injuries. This is important for the team to weigh against the attempt.
Can DNRs be suspended? Yes, certainly, they may be temporarily suspended on discussion with the patients. There are often good clinical reasons to do so dependent upon the causes underlying distress.
Can a patient object to a DNR? Of course, however, the presence of a DNR is not dependent upon the patients consent. If it is in the best interests of the patient then a DNR will apply and neither the patient or the family can insist upon its removal. In much the same way a patient cannot insist upon a heart transplant or any other treatment that is inappropriate.
Should patients be informed about DNRs? Ideally a patient should be informed, however, this is a matter for clinical judgment. In some patients the knowledge would just cause distress.
What happens if patients request CPR to be attempted? If patients request CPR to be attempted, even if clinically there is a small chance of success the health care team should usually respect that decision, however, there is no legal compulsion on a clinical team to attempt resuscitation on a patient who has no prospects of success or who will be profoundly disabled. However there should be an honest discussion with the patient of the quality of life that can be expected post-CPR. If there is a lack of agreement then seeking a second opinion may be required.
Why Should I Consent to a DNR because of Coronovirus / Covid 19 Ultimately, clinicians may have to make difficult decisions about who gets access to ventilators and other treatment.
These decisions are likely to involve scoring patients for key indicators of health. Those with serious clinical conditions and those with extreme disabilities are likely to suffer from these decisions. This is part of healthcare and it always has been. Whilst we may bemoan, the insufficient resources available because of government cutbacks or budget problems within the NHS, this is not the clinicians fault, they must work with what they have.
If there is consent for non resuscitation then it is not an admission that your life is not worth saving, it is note to the clinician that if you are close to death, then you would consent not to run the risk of disability by being brought back. You are consenting to a natural death and one that has at its center the remnants of dignity. It is not however and importantly, a suicide, it is a recognition that quality of life is more important than duration of life and that the fragments of life that may remain are not enough to warrant the risk that they may be shot through with suffering.
You should be aware, that regardless of whether you sign or not, the decision to resuscitate or otherwise will be made by the clinicians. A delay in decision making has a cost and that cost is taking a clinician out of the treatment wards to discuss this issue with colleagues and with family.