DNAR A Users Guide

Here’s the Bad News….

…Everyone Dies!

How do we decide who to resuscitate? BMA “Decisions Relating to CPR” Oct 2007 Local Policy – NHS Lothian (DNAR) Policy 2007 Personal experience inevitably

What are the Chances? Around 15% overall survival to discharge if in-hospital cardiac arrest 42% if VF/VT initial rhythm Only 6% if non VF/VT initial rhythm 5-10% Survival of out of hospital

3 Situations Where CPR would be futile Where there is no benefit in restarting the heart due to poor quality of life Patient choice

When to make decision? “It is not necessary to initiate discussion about CPR with a patient if there is no reason to believe that the patient is likely to suffer a cardiorespiratory arrest”

When To Make Decision? Can be difficult to define in our patient group May not have clear diagnosis End of life Trajectory for “frailty”

Patient/Family Involvement Patients should be involved in all decisions regarding their care This includes CPR Often in Geriatrics patient not competent Then good practice to involve patient’s family in discussion

Patient/Family Involvement “Relatives should never be placed in a position such that they feel they are making a DNAR decision unless they are the legally appointed welfare guardian for the patient”

Patient/Family Involvement “In a situation where death is expected as an inevitable result of an underlying disease…it is an unnecessary and cruel burden to ask patients to decide about CPR when it is not a treatment option”

Patient/Family Involvement Dnar does not mean “Do Not Treat”

Beware Communication is important DNAR decisions can carry high emotional weight and significance with families If patient is competent then shouldn’t be having any detailed discussions with family without their consent

Lothian DNAR Policy Some aspects of policy/form seem to have been written/designed with younger, palliative care patients in mind Form going home with patient

QOL Decisions Lothian policy explicitly states we should not be making DNAR decisions based on QOL. Doctor’s assessments of QOL often at odds with patients/carers perception of QOL

QOL Decisions Always discuss with patient/family in these circumstances

Patient Choice

Medical Grounds/Futility “If CPR would not restart the heart and breathing, it should not be attempted” BMA “Decisions Relating to CPR”

Medical Grounds/Futility “Features associated with almost no chance of success are pneumonia, poor mobility, advanced cancer, renal failure and hypotension”

Medical Grounds/Futility Inevitably high degree of judgement involved Knowledge personal experience Personal Attitudes/Beliefs Ultimately should be consultant decision

Final Thoughts Guidelines and Policies can’t cover every eventuality Variation between practitioners Above all do no harm