Do Not Resuscitate Dilemmas
by Michael Webb-Peploe
Read: Do Not Resuscitate Dilemmas (Part 2)
A Call for Communication
One explanation for the lack of agreement between doctors and patients about whether a DNR order should be places in their notes is that the two groups use different languages. Doctors speak in terms of technology and physical symptoms, and tend to reduce their patient to a biological entity. Patients use a non-technical language that talks of their subjective experience and their place within a network of social relationships. Without care the two parties will never understand each other. Because the patient is unwell, possibly confused and feeling vulnerable, it has to be the physician’s task to exercise that care.
There is also the anxiety that once a decision has been made it can not be changed. A large study of heart patients showed that 2 months after initially saying that they wanted resuscitating if possible, 14% had changed their minds. At the same time, 40% of people who initially said that they did not want resuscitation now thought that they did. The current recommendation is that DNR orders are reviewed every 24 hours and that people are given the opportunity to express their opinion if it changes.
Physicians have been encouraged to move away from a paternalistic approach to decision-making where the doctor decides and the patient simply accepts the decision. Instead a system of informed consent is encouraged. In this doctors give information to their patients, but the decision rests with him or her. In reality this is difficult as the person of their relatives may not be in a position to accept this responsibility.
A third option is to encourage dialogue between doctor and patient where both draw on their areas of expertise. The doctor has the medical knowledge and training, and the patient knows what he or she most wants to get out of life. Together they can come to a shared decision. For this the doctor needs to create an open atmosphere in which information can be freely exchanged and will also need to spend more time getting to know the individual patient.
Caring for The Weakest
Doctors have the responsibility of caring for their patients. Part of this care is to determine the likelihood of any treatment being appropriate to a person. When it comes to decisions about resuscitation there are various scoring systems that can help a physician draw a conclusion based on the available information. Concluding that attempts at resuscitation are inappropriate can in itself be an action of care.
A DNR decision based on the conclusion that attempts at resuscitation would be futile is very different from one based on quality of life’ criteria.
Doctors are privileged to meet people at crisis moments in their lives and provide expert assistance. The highest form of inter-personal relationship is one of respect based on the assumption that all involved can be trusted to provide the best for each other.
The key to providing this high standard of trust is that doctors retain the basic attitude of wonder, respect, empathy and protection. The weaker the person, the more these need to be emphasised.
- New UK guidance on resuscitation calls for open decision making. BMJ 2001;322:509. A new joint statement by the BMA, the Resuscitation Council (UK) and the Royal College of Nursing recommends a change to using the term Do Not Attempt Resuscitation (DNAR) instead of DNR.
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Christian Medical Fellowship (CMF) Files No. 53, 2014