Discussing Treatment Escalation & DNAR

As an FY1 you should not be expected to make decisions regarding treatment escalation and DNAR, but you may need to prompt seniors to consider them & explain these decisions to your patients and/or relatives.

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Definitions and abbreviations

Do Not Attempt Resuscitation (DNAR/ DNA CPR) – this is a medical decision that states if a patient suffers a cardiac arrest that CPR will not be attempted. Reasons for this include; severe COPD, heart failure, multiple co-morbidities, frailty, patient choice

ITU/ ICU: intensive care – level 3 care, 1 nurse to 1 patient, usually for patients with multiorgan failure requiring multi-organ support, e.g. vasopressors, intubation + ventilation, renal replacement therapy (RRT).

HDU: high dependency care – level 2, 1 nurse to 2 patients, single organ support e.g. non-invasive ventilation (NIV) (NB: this can also happen on some normal wards depending on trust), RRT.

WBC: ward-based care – level 1, 1 nurse to 4-6 patients, IV fluids, antibiotics
Remember – patients may sometimes require escalation to ITU/HDU because of increased nursing requirements without escalation in the treatment they receive

Communication tips with patients and relatives

  • Start by discussing the patient’s current health & if relevant, discuss how limitation of carrying out ADLs/function demonstrates that their body is no longer able to cope as well with significant stresses
  • Explain the treatment that will be offered first if necessary: “should they deteriorate we would of course respond with things that might work like antibiotics, intravenous blood or fluids and other treatments on a ward”
  • Explain that it is the duty of a doctor to always explain all treatments because we always prepare for every situation well in advance, however unlikely it is to occur, because these decisions are best made early when everyone is able to think through things properly
  • Establish what the patient or relative understands by terms like CPR, intubation, dialysis etc. and what they involve
  • Ascertain whether the patient or their relative has previously thought or discussed their views on what they would want were they to become very unwell
  • Explain the perceived benefits vs harm – recovery (if successful and commenced promptly following cardiac arrest), rib fractures, undignified death
  • Be clear on what a DNAR is not = i.e. it does not mean that care will stop, and this includes escalation to ITU (if deemed appropriate)
  • Explain that the burden of the decision is on the medical team & that we know the chance of survival even when fit and well from a cardiac arrest is quite low.
    • In people with multiple medical problems, their bodies cannot cope with the significant stresses resuscitation applies.
    • Reassure them that the patient’s comfort and dignity will always be maintained, and decisions are being made in the best interests of that individual patient
  • Listen to and answer questions politely and respectfully
  • A useful phrase I learnt from a consultant colleague: ‘if a person’s heart is the first organ to stop there is a chance of successful resuscitation, however, if the heart is the last to stop then the chance of success is very small’
  • If they do not agree with the decision made, be respectful and ask a senior to discuss and where necessary a second opinion may be sought

Some things to remember

  • Chances of success of resuscitation in hospital patients, in general, are typically very low
  • Even if a person has a return of spontaneous circulation (ROSC), the likelihood of full recovery and survival to discharge remains very low
  • Resuscitation is a medical intervention and as such DNAR is a medical decision
  • DNACPR does not prevent escalation of care if clinically appropriate, a patient may still be considered appropriate for ITU including intubation and ventilation
  • Clearly document in the notes what has been discussed with patients/relatives
  • Communicate the decision on the discharge summary – this can prompt the GP to have these discussions to consider putting it in their community notes too, preventing inappropriate out of hospital CPR
  • Be clear on exactly what is and is not appropriate for your patient i.e. if they are for HDU care only, what does this mean specifically – RRT or NIV? If for ITU does this include intubation and ventilation?
  • Not all ITU care is the same – treatment for hyperkalaemia is very different from septic shock requiring dialysis & vasopressors
  • If any doubt, discuss with your seniors and when you feel confident; why not ask a Registrar or Consultant watch you have a discussion for a CBD or mini-CEX.

Helpful guidance can also be found on the GMC website.

Written by Dr Paula Busuulwa (FY3)

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