A few weeks ago I wrote an article for the Trust on the topic of resuscitation (below). There are many components to this, not least the sometimes forgotten focus on avoidance of its need, that is, within healthcare the role doctors and nurses can play in avoiding a patient’s deterioration and subsequent death. In the NHS this is viewed as the response to the ‘deteriorating patient’ and a fundamental marker of quality of care in a hospital or other care facility.
There is also the science of resuscitation itself which involves the mechanics of what you do, how and when and the underlying physiology and subsequent treatment and support for those situations when a patient is successfully brought back from death. (In recent years for example, it has been discovered that cooling the brain of a patient who has survived resuscitation can aid recovery.)
I am going to discuss documentation.
I know this sounds dull and anyone who knows me knows that I am not a fan of bureaucracy, yet, in this instance it is important.
Before I start I must explain that the state of death I am talking below is a particular one that is when an individual reaches the end of their natural life. Now, this is a tricky topic as the concept of nature is broad and you could question whether three-score years and ten (70) or 86 or 120 is the length nature expects.
Suffice it to say I am talking about old people.
I say old, rather than my usual older as I mean old in its common term rather than the more nuanced and relativistic older. Old in the UK today means (for me) anything beyond 85.
Now, the situation in the UK today is that if you are old and you are ill (or you might just be very old (I have a patient who is 106)), and something happens and you die in your sleep (most people when asked prefer this mode of death rather than a conscious or painful preceding of the moment of extinction) unless you have a document called a ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) completed by a doctor or a nurse, there is a likelihood attempts will be made at resuscitation.
When I discuss this with relatives or patients I usually describe the most common situation where people die in the UK, that is, a nurse or carer goes in to wake the sleeping old man or woman and finds that they have died at some point in the night or early hours of the morning.
They might be warm, they might be cold.
If there is no prior documentation of a DNACPR, at least for care homes and hospitals in the UK (where most of our population die), the carer or nurse must shout for help, call 999 or another sequence of numbers if in hospital and commence if able, CPR until someone tells them to stop.
In the vast majority of situations this is an awful situation for the nurse or carer as they undertake what they know to be a futile procedure, compressing the chest of a person they know to be dead.
How do you know someone is dead? I have sometimes been asked. Well, most people know.
A short while later, the ambulance crew will arrive.
Sometimes the paramedics will arrive at the care home, or in a hospital the resuscitation team and start or continue chest compressions and the like.
It might go on for some time.
Occasionally the nurse in attendance might advise the paramedics or the doctors, ‘He was 100 years old, he was very unwell,’ with the suggestion that resuscitation should not have been attempted at all.
You see, without the piece of paper, there is the belief that resuscitation must be done.
I have seen it happen too many times to remember; mostly in hospitals when I would lead the cardiac arrest team as a medical registrar.
I would arrive on the scene and within moments realise that the actions of the team were futile, the state of the usually naked body (clothing must be ripped or cut-off to allow the defibrillator pads to stick) was beyond saving and, even if ‘saved’ that is, allowed the Return of Spontaneous Circulation (RoSC) would only result in a short-lived period of ‘life’ before they ultimately died.
I don’t want to be too graphic about the events surrounding resuscitation as my aspiration is not to scare, rather, to explain the system in the UK.
If a patient dies in a care home in the UK (or in their own home) without the presence of a DNACPR, the police are called to what is considered an unexpected death, yes, even if that person is 99 and riddled with cancer.
The body will be taken to the mortuary and the coroner contacted.
If no doctor has seen the person in the past month this might even lead to a post-mortem.
I am stressing these points as when I discuss natural death, in other words, passing away, most people don’t envisage this.
Now, most people living in the UK do not have a DNACPR.
There is a school of thought that everyone should discuss death and their wishes, no matter their state of health or age and, I agree there is merit in this. Death as taboo is unhealthy.
In reality doctors or nurses who complete the forms tend to have these discussions with people who they feel have an increased risk of dying. These being people who have significant health conditions, perhaps disseminated cancer or severe frailty, and, what is key, is the involvement if possible of the person to whom the form applies.
If the person is not capable of such a discussion, if they have had a major stroke or had advanced dementia, the usual procedure is to discuss with a spouse or other next of kin.
And this is probably the point of this blog.
My first request, is, that although the level of detail I have provided here is unnecessary for most, the focus should be on death as natural, as an inevitable progression which will affect everyone and, the portrayal that most people die of natural causes in the UK. When death comes, it is almost always unavoidable, with the process of chest compressions and mouth-to-mouth rescue breaths in the very old a futile intervention, one which robs death of its dignity.
During the early phase of the pandemic there were reports of some doctors signing blanket resuscitation orders for care home residents.
I absolutely do not condone this, mainly because it breaks a fundamental aspect of clinical care and support that is, involving the patient or their next of kin in a process of join decision making.
Something people often ask is whether they need to sign anything. I always explain that there is no need. The DNACPR is an indication of wishes not a legally binding document (as opposed to an Advanced Directive).
TV dramas of Lazarus-like resurrections are very rare and almost unheard-of in this group of patients.
A final note relating to resuscitation is that it can be effective in bringing people back to life where they have experienced what might be called an un-natural death, for example a cardiac arrest following a heart attack, electrocution or drowning.
Chest compressions and mouth-to-mouth can and have saved innumerable lives across the world. I am an advocate of CPR which is a skill every citizen should be trained to perform.
Natural and un-natural are perhaps not the best ways of splitting the discussion although most people will get what I am saying.
The discussion, where the doctor or nurse spends time with a patient or relative is in my experience an act of compassion.
There is no law to say that doctors must complete these forms.
It is much easier to change the topic or put it off for another day.
Neither doctors nor nurses look forward to such conversations although most who do so, proceed because they care, because they value the dignity and sanctity of life.
Looking the other way is easy. Stepping forward and acting not so.
Mortality Matters – Issue 2 – DNACPR: What do you say?
DNACPR: What do you say?
Issue 2 – 24 September 2021
Starting discussions about resuscitation with patients, their relatives or carers can be difficult.
Often clinical staff are reluctant to begin conversations as they feel they might upset patients or their comments might be taken the wrong way.
It is a reality of life in the 21st century that dying without the presence of a DNACPR introduces difficulties and challenges that many patients and families would prefer to avoid (involvement of futile resuscitation, the police or the coroner).
There are different situations when DNACPR discussions are important, for example when a patient is admitted to hospital, is in a critical condition and is not appropriate for escalation of treatment, or, when discussing with a patient their options for treatment and care.
A difficulty many colleagues encounter is knowing what to say.
I have learned over many years that one size does not fit all and as with everything in healthcare, taking a person-centred approach is paramount. Timing is also critical as is ensuring the environment is right.
Very often, in my role as a geriatrician, discussions about resuscitation take place as part of a broader conversation about a patient’s recent hospitalisation, their current treatment plan and prognosis.
Many of my patients have extreme frailty and do not wish to be readmitted to hospital if and when their condition deteriorates; this is within the realm of advance care planning to support admission avoidance.
I often begin my conversation by finding out what the patient or their family want or feel, reflecting on recent experiences, the good and the bad.
I frequently explain that we are able to provide adequate and effective treatment in the community, keeping patients in their own homes or care homes and avoiding A&E attendance so long as there has been a discussion about a patient’s preferences.
Many patients prefer to remain at home even if that means they might not survive. Most patients when asked would prefer to die at home with a minimum of medical intervention or intrusion.
To support this wish I create an admission avoidance document.
When I complete this document I usually explain to patients, that in order to have confidence that we can avoid admission or readmission, a DNACPR is appropriate (being sure to explain what the acronym DNACPR stands-for!)
Most often I say, ‘A DNACPR is a document which allows a person to die naturally, it does not mean a person can or will not receive active treatment or care, it doesn’t mean you will be ignored or overlooked; it is a document that provides those caring for you assurance that when the time comes you can be left in peace.’
Every time it is different.
I also feel quite strongly about the decision-making process, being careful to ensure that patients and relatives see that the form and its completion is a medical decision, with the responsibility for this being mine, the doctor.
Occasionally families are left to feel that the decision is theirs, something that can lead to feelings of guilt.
At other times when a relative is unsure and wishes to reflect, yet I feel it is more urgent or appropriate for the form to be completed I will say, ‘I think it best for me to complete the form now, you can talk with your siblings. Please remember that the decision is not your responsibility, all I require is your agreement or support. If you feel the document is inappropriate it can be cancelled.’
As I say, no one size fits-all.
Take your time.
Most patients and relatives welcome the opportunity to discuss this with another person.
If you feel uncomfortable with these conversations please speak with a more experienced doctor or nurse or a member of the palliative care team.
Consultant geriatrician and divisional director for community, therapy and dietetics