Do Not Resuscitate Dilemmas
by Michael Webb-Peploe
‘Do not resuscitate (DNR1) orders can be considered only after discussion with the patient or others close to the patients, and they should be reviewed at regular intervals.’ This is the opinion of the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. Their advice is set against the background where traditionally clinicians determined their patients’ resuscitation status without consulting the person or relatives – a situation that is now regarded as morally indefensible.
Despite this supposed change in attitude, Age Concern England compiled a report showing that DNR notices were regularly posted on the notes of elderly patients without this being discussed with either the people themselves or their relatives.2 An independent review of one of these cases noted: ‘It was hard to avoid the conclusion that the treatment plan… was to do little more than allow the patients’s life to ebb away’.3
The report highlights two areas of concern. First was the lack of communication between medical staff and the people involved in each situation. Secondly there is the concern that the quality of care given to a person declines once a DNR decision has been made.
Rather than coming to the conclusion that treatment is futile, it would appear that on occasions doctors decide that the person’s life is futile.
We need to see how patients as well as healthcare workers view the issue of resuscitation, enabling both to gain a realistic understanding of each other’s viewpoints and then find ways of caring for people whatever their state of health.
Anxiety and Expectation
At the moment the public seems to be developing a growing distrust of the medical profession. Part of this is caused by the fact that doctors don’t always listen to a patient’s views before they come to decisions.
For example, one recent research paper shows that in America only 29% of residents of nursing homes had had discussions with a doctor or member of staff about whether they wanted to be given life-sustaining treatments. Despite this, 74% of the people had DNR orders written in their notes.4
Communication is not just poor between doctor and patient; there is also a lack of communication between the patient and his or her caregivers. Only half of the people who had discussed a DNR order with their doctors had talked about it with their relatives or friends.
Another study looked at people with severe heart disease.5 Researchers found that the doctor’s view of whether a person wanted to be resuscitated if necessary disagreed with the patient’s actual view in one quarter of occasions. Sadly the mismatch between the patients’ and the physicians’ views did not appear to improve if they discussed the situation.
Another problem is that people tend to have an excessively optimistic view of the chances of resuscitation being successful. Television has led to the illusion that a decision to resuscitate will be followed by a sudden rush of medical staff, and a sudden rush of medical staff, and an immediate outcome – either the person dies or survives. In most cases they seem to survive.
The reality is very different. To start with, resuscitation is seldom a single event, but is a long-drawn-out string of interventions. This can include electrically stimulating the heart, mechanically helping the person breathe, and transferring them to an intensive care unit for further treatment. Many patients die a day or two later, with their last day occupied by intrusive and often painful interventions.
On average less than half of patients whose hearts stop while they are in hospital survive the initial event. Of those who survive, only one third live to go home. The remaining two-thirds experience a lingering death in hospital.6
Outside a hospital situation is even worse. Resuscitation may succeed in as few as 2% of people whose hearts stop when they are not in a hospital.
In many cases the chance of resuscitation being successful is minimal and it must be more appropriate to let the person die with dignity. For example, there is basically no chance that cardiopulmonary resuscitation (CPR) will save the life of someone who has pneumonia or advance cancer and then has heart failure.7 In these sorts of situations the attempt to resuscitate is a futile exercise denying the person a dignified death. If the patient is elderly, there is a high chance that the force needed to compress the chest will break some ribs. This causes intense pain and complicates further treatment.
Consequently most doctors believe DNR orders are appropriate if the person is dying from a progressive incurable disease. What is disturbing, though, is the suggestion that DNR orders may result in a reduced quality care and attention that a person is likely to receive. One study found that a patient was more than thirty times more likely to die if she had a DNR order in her notes than another person who was equally unwell.8
Read more: Do Not Resuscitate Dilemmas (Part 2)
Christian Medical Fellowship (CMF) Files No. 13, 2001