TL:DR – A Do Not Resuscitate note (DNACR - Do Not Attempt Cardiopulmonary Resuscitation) is not a Death Warrant. It’s a clinical decision, only taken when all evidence suggests that a complex, last resort procedure with approximately only a 1 in 4 survival rate, is unlikely to succeed. DNRs are a clinical decision, which is always taken within the guidelines set out by the law. and medical ethics. The law in the UK has not changed.
Content Warning - Discussion of death, resuscitation, injury - below the read more tag.
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There have been a lot of at best misguided or misinformed, at worse baseless and damaging, material being shared around social media in relation to Do Not Resuscitate codes – also known as Do Not Attempt Cardiopulmonary Resuscitation (DNACR) or Allow Natural Death (AND). In the last 24 hours I have seen doctors being piled on both directly and indirectly on social media for placing DNACR some individuals (often those of advanced age) – from questions of ethics, claims it is illegal, and in some cases alleging murder / hate crimes. Not only is this based on a complete ignorance of the law, and of medical practice, it is in effect emotional violence against people who are already under pressure and who are more than well aware that lives depend on their decision making in the best of times, and even more in these times. Naturally death, and end of life care, are emotive topics, but I feel that it is worth including in this collection of notes from the current pandemic some discussion of these issues.
So here I just want to set out a couple of basics about DNACR – and a couple of factors relating. I should make it clear that this is something I have personal experience of – having lost more than one immediate family member to terminal conditions which involved both DNACR and decisions to withdraw life support. I also have experience of discussing the ethics of this with a friend who was dying from advanced cancer – and who was writing an Advance Directive (which is not the same as or related to DNR).
First off a clinical misconception. Cardiopulmonary Resuscitation is not a practice which is done on the living. It is done on the recently deceased. It is only attempted on a patient who is not breathing, and has no heart activity. It is an attempt to restart processes which have already stopped. The patient has in effect already died. In crude terms the procedure is an attempt to resurrect them after a natural death has occurred – while attempting to minimise hypoxic brain damage (from the lack of oxygen to the brain – which happens during death, and can also happen in a number of other situations – I myself am a survivor of intrauterine hypoxia). The odds of a patient returning to spontaneous circulation (ROSC) – are around 1 in 4 if the resuscitation takes place in a hospital. The odds drop outside of this framework. Around 13% of all patients (surviving and not) suffer injuries as a result of CPR, which can include broken ribs or sternum (a broken sternum in and of itself is a dangerous injury), and internal injuries (e.g. heart contusions, damage to the liver and spleen, pulmonary complications, etc). Patients often vomit as a result – requiring intervention to keep their airway clear. On top of attempting to restart breathing, there are attempts to restore heart rhythm – defibrillation etc. One study in Copenhagen found 22 of survivors suffer from mental problems as a result, with some 11% needing some form of support on a daily basis. There are reasons why Cardiopulmonary Resuscitation is a last resort procedure. All of this assumes the patient is generally fit and well – other conditions can create huge complications. This type of resus is also contraindicated in the very young where it can cause severe complications and in fact make the situation worse. In the case of my father – when a DNACR was discussed he made it clear, while having somewhat limited agency due to his condition – that this was his preferred course of action. He wanted to be allowed to die naturally. In the end, he slept, before going into a coma, and passing away naturally some days later.
Secondly, a DNACR is a clinical decision. Like any clinical decision it is take by doctors, governed by the law, best practice, and medical ethics. No patient is in general asked to ‘sign a DNR’. It is not the patient’s choice in this respect. Provided they have capacity the patient may make an advance directive – which gives an indication of their wishes should they lose the mental capacity to make those decisions for themselves – this is however totally different to a DNACR. A DNACR is not a death warrant. It is a record that in the clinical opinion of the doctors concerned that attempting Cardiopulmonary Resuscitation is not in the patient’s best interest. This can be taken for a number of reasons unique to each case. The likelihood of the individual’s survival is key - it is about whether or not attempt the procedure would in effect be futile. Quality of life can be a factor in discussing the matter with a patient - this was the case with my father – who had only minimal movement in his hands and facial muscles but could not swallow and could barely speak. The probability was that even if resuscitation attempts succeeded these remaining things would be stripped away from him - which led to his expression of a desire to be allowed to die naturally. In his case, his decision to support the doctor’s decision was grounded in his own faith. In his view, when it was his time, his guardian angel would appear to him, to lead him on his soul’s journey into the next world. All clinical decisions are taken with the patient’s best interests at heart. In his case – he was allowed to die naturally, and was respected. Personally, I am extremely grateful to the doctors who cared for him in his final days.
The discussions between doctors and patients around DNACRs are part of transparency – they are not a question of being asking to sign off on the forms etc – this is a misunderstanding at best, and a misrepresentation (by some irresponsible journalists) at worst. A DNACR is not a death warrant. It does not mean the patient won’t get into hospital, won’t get oxygen, etc. It relates specifically to Cardiopulmonary Resuscitation. The specific medical procedure discussed above. It is not taking away a patient’s rights or consent. It specifically relates to a procedure done when a patient in the terminal phase of natural death – or depending on clinical definition used just after it. These conversations should take place when clinically appropriate – but naturally the ongoing pandemic has focused people’s minds – especially as the transmission risk has stripped away some of the usual structures around death and dying practiced by people of all faiths and none. Some medics have, perhaps, not phrased things particularly well when discussing such matters. All doctors, and all patients, and doctors who are patient, are humans. (At the request of a colleague I should point out discussions around death are no easier in veterinary medicine – and as someone who has presided over funerals for a number of animals in my time I fully agree). We make mistakes. We phrase things badly. At times like these, when the medical infrastructure is under pressure – things get shaken lose. Maybe this discussion was meant to be had a few months ago – maybe in a few months. The pandemic is focusing minds on many things around end of life care. However, and I cannot emphasis this enough the law in the UK around DNACR has not changed. There are no references to it in the recent legislation, and medical guidance remains, as far as anyone I have consulted, the same.
Naturally this is an emotive topic for many. Death is an emotive issue. In the West, we distance ourselves from death. We distance ourselves from dying. As a result it is an emotionally raw topic. This is something which, with my own mixed background, I find strange – coming from a blend of cultures which have some fixed rituals around death and dying which most people know and will have discussed in advance. It is something we all have to face. It has been called “the debt which all (humans) pay.” It’s an inevitable consequence of life. The focus of doctors, families, priests, is in some ways similar – to help someone have a good death, by whatever definition that may be.
If you choose not to believe me, given I am a researcher who works on medicine, palaeopathology, and historical epidemiology, here is a thread from a medic discussing the same matters in slightly more detail around the legal and clinical aspects.
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A thread on DNACPR (Do Not Attempt Cardiopulmonary Resuscitation). (1/29)— Beth Routledge (@sefkhet) April 5, 2020
