The referral from my junior colleague hadn’t sounded hopeful over the phone; a rapid deterioration in breathing in a 97-year-old patient with history of heart failure, a previous stroke, and a current pneumonia.
The oxygen saturation monitor beeped urgently from beside the bed, but this couldn’t begin to drown out the rattle emanating from Mr Hamble’s chest.
He was gasping for breath, his frail body fighting the flimsy blanket that covered him with every desperate gulp for air. He wasn’t responding to his antibiotics, and his pneumonia was taking hold.
I was busy listening to his chest with my stethoscope as his nurse entered the room, wheeling an ECG machine behind her. She smiled weakly at me, her face etched with concern.
“He doesn’t have a red form,” she announced, glancing nervously around the room. The “red form” was code for a Do Not Attempt Resuscitation (DNAR) order. I turned to Mr Hamble’s son.
“Do you mind if we have a word outside?”
He seemed unwilling to leave his father, but followed me towards the deserted nurses’ station. He sat down opposite me, his hands still wrung before him. I began to explain how unwell his father was, and how limited we were with any further options.
He shook his head slowly. “I don’t want him to suffer. He’s had enough, and he wouldn’t want to carry on like this.”
We spoke for a few more minutes, before he returned to his father’s side. I reached into the bottom drawer beneath the nurses’ station, and began filling in a red form.
The issue of Do Not Attempt Resuscitation (DNAR) orders is complicated.
Used appropriately, they avoid traumatic and unnecessary attempts at keeping very unwell patients alive, and provide a shred of autonomy for those nearing the end of their life.
The problem seems to be, though, that there is great contention about when DNARs should be initiated, and who should be involved in ultimately making such a decision.
There have been recent high profile legal cases aimed at doctors who have failed to notify relatives of DNAR orders, such as that of Janet Tracey at Addenbrooke’s hospital in 2011. The subsequent guidelines released by medical bodies in response to this appears to have led to a notable change in the approach to initiating DNARs.
The advice highlighted the importance of including patients and their relatives in the decision-making process, but seems to have led to a reluctance to deem anybody unsuitable for the trauma of a full resuscitation attempt, the majority of which lead to nothing more than broken ribs and failure.
And what if the heart is restarted?
Elderly, frail patients do not respond well to post-resuscitation care, and the Intensive Care Unit (ICU) usually deems them unsuitable for transfer to their department.
DNARs do not mean that the patient is not going to be treated, just that we are not going to intervene should treatment ultimately be unsuccessful.
Involving relatives in the decision making process is admirable, but can also be unfair. There is invariably guilt associated with any decision that a loved one should not receive all the care that is available, and often a Holby-City-induced belief in the efficacy of resuscitation.
We as doctors need to have early and realistic discussions with patients and relatives, and be actively involved in documenting accurate and thorough plans in case of a patient’s deterioration. Because even when a DNAR decision is made, there is often still a huge amount of uncertainty.
Is the patient still potentially an Intensive Therapy Unit candidate? Is active treatment still indicated? Should we still be monitoring the patient’s observations?
Whether it’s fear of legal action, an unwillingness to outline a ceiling of care, or simply a belief that the frail and disease-ridden patient will respond well to resuscitation, these decisions are not being made.
Mr Hamble died a few hours later, with the DNAR form filed visibly in the front of his notes. My senior colleague was surprised I’d been happy to discuss the issue with his son.
It is never an easy conversation – those regarding death rarely are – but one that we as doctors must be prepared to face.
Mr Hamble is a pseudonym. This article was originally published on the Guardian website and reproduced with permission.