The statements below do not reflect my practice, my biases or my decision making process.
There is no intention to trivialise the issue, but there is an intent to attempt at frivolity
All of us want to make the right decision. But let us not kid ourselves; the recent issue about the DNAR generated by the court order (court document: / uk resus council guidance) is not about making the right decision or giving the right treatment for the right patient, but instead about being seen as making some decision, being seen as having some discussion and ultimately documenting something so that it stands up in court if or when a relative escalates the issue.
Forget the actual decision, forget the decision making process, forget documenting; we are having trouble just getting discussions started in 93 year old stone-deaf people, the 50 year old bed-bound woman with severely disabling multiple sclerosis and the 40 year old with advanced alcoholic cirrhosis with an off- the -scale Child-Pugh score on his usual admission yet again this year. We now need a trigger to start discussions off in everyone admitted through the hospital doors to meet legal requirements. Solutions are popping up everywhere to help patients in hospital beds to engage with their own death-bed scenarios. A leaflet? A poster? An overhead TV screensaver reading "DNAR- Now available to everyone on the NHS"? A local radio station DJ singing “Ask about D-NAR” along Y-MCA lines? A badge on the beautiful nurse which reads “ it is ok to ask about DNAR” (while you ask about my hand-washing skills)? An offer of patient choice of hospital gowns with "FOR" or "NOT FOR" printed in fluorescent yellow? I am full of ideas today I am.
So we have concerns about inclusion as well as exclusion.
With regards to inclusion: The court states: "If the clinician forms the view that a patient will not suffer harm if they are consulted, the fact that they may find the topic distressing is unlikely to make it inappropriate to involve them.”
The court has in effect stated that patient's emotional distress is not harm?. Or maybe, the court has stated that the potential to cause emotional distress is not harm. So, in effect we are left with having to start discussions with people who we know are very likely to be emotionally distressed by the discussion, often pointlessly, and then stop half-way when we find them in emotional distress and leave them wondering what would have been had the conversation been completed…??
With regards to exclusion: “The distress must be likely to cause the patient a degree of harm to warrant them not having the decision discussed with or explained to them." I am keen to avoid emotional distress to my patients when they are most vulnerable. I am keen to write in many instances that I feel that it would not be appropriate to discuss the issue of CPR with this patient in front of me. But how do I document the perception of a degree of "emotional distress" that can equate to "legal harm"?
Apparently we are not supposed to be concerned about our own distress with all of this as human beings, but apparently the court expects every one of us when we qualify as doctors suddenly to be efficient DNAR machines, moving from patient to patient, discussing heartlessly yet empathetically, rapidly yet effectively, legally yet ridiculously. In a setting in the near future, where I refuse to discuss DNAR with a patient(s) due to my concern about it potentially causing significant distress to both me and the patient, I think it would be helpful if we had a few doctors available at hand who have been on courses and returned as "DNAR officers" who have the authority to identify "legally acceptable patient distress", who then goes around with a fixed state of mind on "DNAR rounds" perhaps, to ensure everyone is treated equally? It would be even better if these DNAR officers were lawyers or judges who can make better decisions since they are apparently well qualified to make decisions about decisions that they never have to make themselves.
A DNAR discussion in the community can make our job easier in some cases(if they have chosen against CPR) , and more difficult in many cases( if they have chosen pro-CPR), but no less in terms of numbers, as everyone will still need to have had a discussion with at admission to hospital..
So, what can be done to engage patients in the issue of their own potential for mortality during an otherwise seemingly innocuous hospital admission?
“if a clinician considers that CPR will not work the patient cannot require him/her to provide CPR. It states that this does not, however, mean that the patient is not entitled to know that the clinical decision has been taken.” We all agree that the patient is entitled to know it. But we would like some patients to initiate the conversation though. So, then, should a leaflet at admission merely highlight this entitlement perhaps, with a generic approach including, welcome to the ward…., the ward facilities are….and by the way you are entitled to look at your drug charts, monitoring charts and particularly case notes if you would like to know or discuss about your DNAR status. If the patient does not read or reads but does not discuss, doctors still stand the risk of going to court.
So, going one step further, the leaflet handed over to clients entering the hospital premises could have a tear off section with tick box options:
1. I want to discuss my resuscitation status every time I get admitted.
2. I do not want to discuss my resuscitation status but want my relatives to have the discussion on my behalf (although the ultimate decision will be the doctors’
3. I do not want to discuss my resuscitation status and I am happy for the doctors to make the DNAR decision on my behalf depending on my suitability for the treatment.
4. I do not want to be resuscitated. I do not want to discuss this further. Ever.
Notably, there should never be the option 5: I want to be resuscitated. That would always be a patient's wish list and a doctor's decision. Thankfully that is not in question this year. Not yet.