Friday, August 04, 2006


Enter the District Nurse Team Leader *no-- not to the Dambusters March or 633 Squadron* clutching a sheet of paper with a half inch thick red border. This is my least favourite American Import. It is a DNAR.

Do-Not-Attempt-Resuscitation Form.

The patient she wishes the DNAR to apply to has lung cancer, pneumonia, severe arthritis and a number of other ailments. Despite this he is relatively well symptom controlled, but visibly fading. In the past week he has gone from ambulant to bed bound, and from eating and drinking normally to nil by mouth. He is plainly terminally ill after a life well lived, and is not at all distressed except when people try to make him leave his house to go into a nursing home.

Unfortunately he is now almost totally dependent, and so requires round the clock carers since he is estranged from his family (who wanted him to go into a nursing home). Under the terms of their contract the Round-the-clock-Care-Agency (TM) oblige their staff, all former nurses, to pound the chest of any "client" they find to have died on their watch. Unless they are covered by a DNAR.

Sooo here I am on a Friday afternoon talking to a dying man, reminding him of the fact, and asking him if he would like the nice lady to attempt resuscitation should the inevitable occur over the weekend.

This sucks.

He gets reminded of the fast fading light. And all to meet some contractual stipulation imposed by an unfeeling bureaucracy intended to keep the PCT out of the courts. I am still at a loss to understand just how this poor man's care has been enhanced by today's little mise en scene.

Sadly, these days, his is a relatively simple case. At least he has a diagnosis and a prognosis which are fairly clear cut. This is not intended to sound callous. I feel for all my terminal patients, and do my level best to palliate all the symptoms of their final illness, but consider for a moment patients with a more protracted, less predictable course. COPD, Heart Failure, any of a dozen Neuro-degenerative diseases.... even Rheumatoid Arthritis. All have the potential to cross over a tipping point to become "terminal". So when and how should we be having the DNAR chat with them.

It is all too easy for that little talk to turn into the bleakest message you will ever hear. Worse than diagnosis. Worse even than a terminal prognosis. It implies something along the lines of "Sorry old chap, but we feel it's time we gave up on you. Perhaps you'd like to think about doing the same eh, there's a good fellow."

When my time comes, however it comes, I would far rather decisions to resuscitate or not were made at the time and not logged in advance. There may be some grey areas, but most decisions can be arrived at with the application of a little common sense at the time and given the circumstances then prevailing.

I pity the poor fellow who gets to bring me my DNAR for signing up. I think I might start practicing my "Henry Fonda" act now in readiness.


Shinga said...

From Tigger to end-of-life conversations - you GPs lead a richly varied life. I admire your ability to cope with the ethical intricacies and difficult conversations.

Regards - Shinga

Moof said...

Dr. Jest, I agree with you. You said it very well here:

"There may be some grey areas, but most decisions can be arrived at with the application of a little common sense at the time and given the circumstances then prevailing.

Medicine is losing its human touch. Orders like these are signed, and then like a well calibrated clock, tick into place ... no room for human decision ... no room for human compassion.

Thank you ... this was an excellent post.

The Boy said...

Ach, this is tough. In the last year had to agonise over putting a DNR order on my father whilst he lay non conscious and supported by life support. It was not fun, but it was necessary and made the decision the family's, not left with the medic on duty. Given his condition, that could change regularly, and could be left with someone who knew little of him or his case.

So, though not wanting to generalise, each case has its uniqueness, there are times when pre-discussion is necessary too.

It can't be easy for you medics though. I really felt for the doctors who talked us through the options. Though very professional and sympathetic, no options where forced on us, it was clear they were distressed by the situation as well.

Doctor Jest said...

shinga-- you should see me tap dance ;-)

moof-- the day they squeeze out all compassion is the day I hang up my stethoscope. Thankfully I think we are a ways off that, but there are days when it feels like a bit of a rear guard action.

the boy-- Sorry to hear of your troubles. There is a bit of a difference when the patient can no longer speak for themselves, but I am not sure that as a family member I would be in a position to reliably reflect the wishes of my nearest and dearest any more than anybody else. It's a heck of a thing to be asked, and , as you recognize, to have to be asking. The key is information and compassion, and I take it from your comments that you felt you were given both. I don't doubt that it was still the toughest call you have ever been asked to make, and I am sure that you will have made the best choice you could.

One way around the problem is the "Advanced Directive" spelling out your wishes before having to be asked. Jehovah's Witnesses pretty much all do one to clarify their refusal of blood products in the event of accident / surgery. We might all do one stipulating when we would be unhappy to have resus attempted.

Stu Savory said...

I seem to have read somewhere that there is an old lady (in the UK?) who had DNR tattooed on her chest? Is this true or is it an urban legend?

Secondly, surely a DNR is only needed because the country concerned has not regulated euthanasia/assisted suicide/etc adequately? It is for that reason that some terminally ill Germans have taken a one-way trip to Switzerland or Holland in order to be able to die with dignity.