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.
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.
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.