Manor Field Surgery Blog #5 DNACPR

It is part of the job of a doctor to discuss resuscitation with their patients; Do Not Attempt Cardio-Pulmonary Resuscitation (or DNR – Do Not Resuscitate) for short has, over recent years become an important component of care, particularly of older people and especially those who are perceived to be in the last years of their lives.

CPR – Cardio-Pulmonary Resuscitation is rarely successful in any situations, although for those experiencing a heart attack or irregular heart rhythm (Ventricular Fibrillation or, VF as they say on Casualty), it can save a life. It can literally be the difference between life and death.

As a doctor, I often feel uncomfortable asking a patient for their views on resuscitation. It sometimes seems a little like, ‘If you died, what would you like me to do? Stand back, or have a go at saving you?’

It is all very much more complicated than this and that is the problem.

Most people who die today in the UK are older (remember blog #2 – that means anyone older than me) – although, if you look at our average life-expectancy, for women this is 83 and 80 for men. You live longer if you are richer, don’t smoke, or live in the South of Europe or Japan.

And, when we die, as we all must do, most people experience a natural death – whether this is from ‘old age’ itself – your body giving-out or from dementia, now the UK’s leading cause of death, the process tends to be slow, controlled, that is, with back-up or support from nurses, doctors and others, either in your own home, a care home, a hospital or a hospice.

This is a difficult subject and you can probably understand why for those people responsible for asking the question, it is equally challenging.

I simplistically split death into three groups – those where someone is dying, perhaps from dementia or advanced cancer, in which case, doing all you can to ensure the person’s comfort is paramount, offering palliative care, avoiding the potential trauma of late-night emergency ambulances and visits to A&E and so on, is important and, those who die, maybe the best way to put it is prematurely – a heart attack in your 50’s, infection, trauma or another acute medical condition – blood clot, haemorrhage, drug overdose.

The first group are those for whom a DNACPR is often appropriate (I will explain more) and the second, probably not.

The third group is people who don’t necessarily have a disease but just pass away. Die in their sleep, often from old age.

When is it OK to die in your sleep?

In your 80’s, 90’s?

100 years ago, dying in your sleep in your 70’s was the considered a good-innings. Where will we be in another 100 years?

It is currently, standard practice (although infrequently done) that we ask anyone over the age of 75 their views on resuscitation.

Some people argue we should ask everyone no matter their age (there are not many of them);

Before I go on, and I promise to make this short; there is a sense that when someone has a DNACPR, clinical staff or nurses relate differently to the patient, such as, ‘Oh, he has a DNR, don’t worry that his blood pressure is low,’ for example. I think this was a thing of the past although culturally we are changing as is the training of doctors and nurses and given that DNACPR is so much more part of our culture it is far less associated with ‘Do Not Treat/Care’ than it used to be. (There is more here).

So, do I have a DNACPR?

No.

If I had advanced dementia and was bed-bound, unable to communicate with a high probability of dying in my sleep, would I desire a DNACPR?

Yes.

Unfortunately, the person with advanced dementia is often unable to participate in the process of deciding and what is called a best-interests decision is made by the doctors in discussion with next of kin. Again, that is often how it is.

I wrote a few years ago about people with Locked-In Syndrome and research that demonstrated that for some of these who are unable to move at all except blink, they report a reasonable if not good quality of life (provided they receive high-quality care and support).

It is very difficult to anticipate the future just as it is hard to determine what is right for someone else.

I haven’t really touched-on the outcome of CPR – the very small numbers who survive resuscitation, particularly those in hospital – who are often also very sick with multiple additional health conditions; that is for another day.

For now, perhaps just think about resuscitation, what you would want, whether you are young or old, healthy or not.

And, if someone asks, it is after all just a question.

Just a final point – this is all very different from organ donation which should apply to everyone, although, like all of this, that is just my opinion.