1. DNAR
A Users Guide

2. Here’s the Bad News….

3. …Everyone Dies!

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

5. 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

6. 3 Situations Where CPR would be futile
Where there is no benefit in restarting the heart due to poor quality of life
Patient choice

7. 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”

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

9. 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

10. 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”

11. 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”

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

13. 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

14. 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

15. 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

16. QOL Decisions
Always discuss with patient/family in these circumstances

17. Patient Choice

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

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

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

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