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Rapid Responses: Rapid Responses published:
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DNR: an unresolved debate
- Harmesh Moudgil (26 February 2006)
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To ‘focus’ on DNAR discussions in the first 24 hours: practically possible for the medical registrar?
- George I Varughese, Sharmistha R. Chowdhury (26 February 2006)
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Patient factors are only part of the “barriers” to implementing a policy not to attempt resuscitation
- Dylan G Harris (27 February 2006)
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Minimizing Practical Barriers to Resuscitation Maximises Autonomy
- Peter M. Maskell (28 February 2006)
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Consent for resuscitation: the paradox
- Stephen J Fletcher (28 February 2006)
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Refusing to take part in a study about a discussion is not the same as refusing to discuss
- Benjamin AJ Reddi (2 March 2006)
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Harmesh Moudgil, Consultant Physician Princess Royal Hospital, Apley Castle, Telford, Shropshire. TF1 6TF
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Editor, Fidler et al [1] add to debate on do not resuscitate (DNR) instructions and although primary interests were to establish reasons for not involving patients in decision making the study would have been better served in at least providing a more appropriate overall measure of the problem. Taking the denominator as all patients being admitted and concluding with a statistic that for 80% decision making is not possible is not relevant. It would only be meaningful if that knowledge about resuscitation preference would have actually dictated subsequent anticipated clinical events in all these patients. For unexpected outcomes the default should always be to resuscitate as we otherwise have an unexpected death. Routinely asking all patients to consider a decision would, as stated, contribute to more anxiety and against the ethos of firstly doing no harm. Importantly, there has also previously been concern that the quality of actual care reduces with a decision for DNR, even adjusted for age and disease severity [2]. Our skills should be able to identify those patients who should have decisions made early and previous debate had always concerned itself on stereotyped decision making based on patient age or known malignancy. In a previous audit from this Trust [3] we suggested an overall point prevalence figure of 10% for DNR decisions and, although disproportionately involving elderly patients, they all had significant co -morbidity. Patient with malignant disease did not appear to be a particularly identified group. It would have been helpful in the presently reported study to identify what proportion of the total actually required decisions on resuscitation to be made and of these identify those capable of making those decisions and then those willing to undertake discussion. The debate will never end on this as we integrate more from the patient's angle but, as the authors remind us, until that time that our own practices also improve, the profession must remain surrogate decision makers. References [1]Fidler H, Thompson C, Freeman A, Hogan D, Walker G, Weinman J. Barriers to implementing a policy not to attempt resuscitation in acute medical admissions: prospective, cross sectional study of a successive cohort. BMJ 2006;332:461-462 [2]Shepardson LB, Younger SJ, Speroit T, Rosenthal GE. Increased risk of death in patients with do-not-resuscitate orders. Med Care 1999;37:712- 37. [3]Taylor L, Moudgil H. 'Do Not Resuscitate' Instructions: a measure of our practices. BMJ 2001, Feb 2 (on-line) Competing interests: None declared |
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George I Varughese, Specialist Registrar in Endocrinology & General Internal Medicine University Hospital ofNorth Staffordshire, Stoke-on-Trent ST4 6QG, Sharmistha R. Chowdhury
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We read with interest the comments by Fidler et al [1] on the ‘Barriers to implementing a policy not to attempt resuscitation in acute medical admissions’. They acknowledge that within their study group; 111 out of the 185 patients who had been approached declined to participate (reiterating the importance of the issue of causing undue anxiety). Nevertheless, one important aspect that has not been mentioned in the study is how many out of the 74 patients who consented to participate in the study would have possibly required a decision/discussion of the topic – i.e. were they ill enough to warrant that? Perhaps, they were reasonably fit enough not to even worry about the likelihood of the need for a ‘do not attempt resuscitate’ (DNAR) decision, hence the more positive response from that sub-group. Likewise amongst patients who declined consent, it would be important to know how many of them were unwell enough for the admitting team to have considered these issues if it was not for a study, but an otherwise normal general medical ‘take day’. This is particularly relevant as these patients probably did not want to think of the worst and prepare for the unknown in unfamiliar surroundings, within the first 24 hours. One should not forget that in all hospitals that we have worked in the NHS, DNAR decisions cannot be made by anyone less than the rank of a medical registrar (the senior most medic on site during out of hours and also mostly during working hours on the medical admissions unit). In this era, where a typical medical-take is particularly hectic and demanding for the medical registrar and there are patients on the wards who would be requiring DNAR decisions [2], how practical would it be for the medical registrar to focus on this topic in the first 24 hours of admission on a medical take? Obviously, if a terminally-ill patient on a medical take requires a DNAR decision, this will almost always be discussed in conjunction with the patient / relatives as deemed appropriate within 24 hours. Indeed, the health professional will also continue to carry the responsibility for the DNAR decision in the best interests of the patient. [1] Fidler H, Thompson C, Freeman A, Hogan D, Walker G, Weinman J. Barriers to implementing a policy not to attempt resuscitation in acute medical admissions: prospective, cross sectional study of a successive cohort. BMJ 2006 Feb 25; 332(7539):461-2. [2] Varughese GI. Junior doctors' shifts and sleep deprivation: please make on-call rooms available to doctors at night. BMJ 2005 Sep 3; 331(7515):515. Competing interests: GIV and SRC are specialist registrars in Endocrinology & General (Internal) Medicine on the West Midlands and All Wales rotational training programmes respectively and are involved with DNAR decisions during acute non-selective general medical takes. |
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Dylan G Harris, Specialist Registrar in Geriatric and General Medicine Department of Adult Medicine, Nevill Hall Hospital, Abergavenny NP7 7EG
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Dear Editor, Fidler et al. discuss barriers to implementing a policy not to attempt resuscitation in acute medical admissions in terms of patient factors: either patients were not able to discuss these decisions for practical reasons or they did not wish to do so (1). Discussion of decisions relating to cardiopulmonary resuscitation (CPR) is a two-way process and doctor-related factors are also highly important. Even when patients are in a position to discuss resuscitation, doctors often choose to discuss with the family rather than the patient themselves (2). There is a balance between a desire to do good, not to do harm and a respect to patient’s autonomy. Whilst the current resuscitation guidelines advocate that doctors should discuss resuscitation decisions with patients (3), this is a contentious issue (2) (4) (5). Doctors themselves may have personal difficulties discussing such issues openly, or feel that the discussion may not be of positive benefit to the patient (and may in fact be harmful) as it may force patient to confront the inevitability of their fate, it also forces patients to make a choice when in reality they have no choice. Finally patients may have an unrealistic appreciation of the consequences of resuscitation as there is a very optimistic and unrealistic lay view of potential success of CPR. (2) (4) Conversely, it can be argued that poor communication leads to poor patient satisfaction, that CPR discussion is as important as that of any other treatment and that silence or incorrect information heightens fear, anxiety and confusion of patients and families. In addition doctors have been shown to be inaccurate in predicting the views and wishes of patients. Communication about resuscitation orders may be improved if they are discussed within the context of treatment plans rather than as a separate area of discussion. (2) (5) Patient factors are only part of the “barriers” to implementing a policy not to attempt resuscitation, whether doctors should discuss such decisions with all patients is a highly debated issue and a wider review of the current guidelines is needed. (1) Fidler H, Thompson C, Freeman A, Hogan D, Walker G and Weinman J. Barriers to implementing a policy not to attempt resuscitation in acute medical admissions: prospective, cross sectional study of a successive cohort. BMJ 2006;332:461-2. (2) Harris DG, Linnane SJ. Making do not attempt resuscitation decisions: do doctors follow the guidelines? Hospital Medicine 2005;66:43- 45 (3) British Medical Association. Decisions relating to cardiopulmonary resuscitation: a joint statement by the British Medical Association, The Resuscitation Council (UK) and the Royal College of Nursing. British Medical Association, London 2001. (4) Manisty C, Waxham J (2003) Doctors should not discuss resuscitation with terminally ill patients: FOR. BMJ, Sep 2003; 327: 614 - 615. (5) Higginson IJ (2003) Doctors should not discuss resuscitation with terminally ill patients: AGAINST. BMJ, Sep 2003; 327: 615 - 616. Competing interests: None declared |
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Peter M. Maskell, Specialist Registrar in General and Geriatric Medicine Kent and Sussex Hospital, Tunbridge Wells. TN4 8AT
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The paper on resuscitation by Fidler et al. raises the awareness of an intervention that is as traumatic to perform as to discuss. It provides some much needed evidence base on the practical difficulties inherent in the BMA and Resuscitation Council guidelines, which recommend discussion with all patients regarding resuscitation. It is heartening that the small number of patients agreeing to participate found discussions about resuscitation enlightening and wanted to be involved in the decision making process early on in their admission. One of the major drawbacks with the validity and generalisability of the results is with the large proportion of subjects not included in the study. It would not be unreasonable to assume to be these are more likely to object to such discussions. One way to reduce the numbers of exclusions due to logistical problems would have been to revisit them within 24 hours. Also, in the case of those judged by medical students as unwilling to talk about resuscitation, a senior doctor could have made a subsequent visit. Assessing patient’s views of resuscitation at 24 hours is useful, but a significant number of patients will need these decisions made on presentation. These patients typically are physiologically unstable, with variable mental capacity and elusive relatives. Often in these time pressured situations, the co-operation between all health care workers involved is at its best and answers are found when it is vital to make the correct clinical or ethical decision. The study published as it was, however, did demonstrate that practical issues are a major factor hindering prompt autonomous resuscitation decisions. Time invested here will reduce the spectacularly unrealistic views held by some patients and allow patients choice in this area. Peter M. Maskell Specialist Registrar in General and Geriatric Medicine drpeter@doctors.net.uk Competing interests: None declared |
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Stephen J Fletcher, Consultant Intensivist Bradford Teaching Hospitals Bradford BD9 6RJ UK
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Sir, The work of Fidler and colleagues is extremely valuable and confirms the every day experience of workers in the acute specialties. [1] Intensivists are referred patients for whom intensive care unit admission is unlikely to avert death. Attempting to discuss patient preferences in these situations is arguably more difficult than discussing the single question as to whether cardiopulmonary resuscitation should be attempted. Critically ill patients rarely have ‘capacity’ and even when the patient appears orientated and rational, experience shows that subsequent retention and recall of discussions about treatment is impaired, or not present. [2] Retention and recall of material is a prerequisite for valid consent. The logical corollary of this is that the patients identified by Fidler and colleagues who were willing to discuss resuscitation status were unlikely to be critically ill, i.e. those likely to require resuscitation. It would be interesting to test this hypothesis by looking at severity of illness scores in this group and mortality, but I suspect that this paradox is correct; patients most likely to require resuscitation are those least likely to be able to discuss their preferences. Yours, Dr Stephen J Fletcher
[1] Fidler H, Thompson C, Freeman A, Hogan D, Walker G, Weinman J Barriers to implementing a policy not to attempt resuscitation in acute medical admissions: prospective, cross sectional study of a successive cohort Br Med J 2006;332:461-2 [2] Papadopoulos MC, Davies DC, Moss RF, Tighe D, Bennett ED Pathophysiology of septic encephalopathy: a review. Crit Care Med. 2000;28:3019-24 Competing interests: None declared |
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Benjamin AJ Reddi, SHO General Medicine Queens Medical Centre, Nottingham
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Dear Editor, Fidler et al put forth a compelling argument, however, interpretation of the data produced in the study is not entirely straightforward. The conclusion reached by the authors is that '30% of the sample refused to discuss resuscitation' during the first 24 hours of admission, yet this was not the question asked. In fact the study sample were asked two additional questions: Would they mind taking part in a study during the first 24 hours of an acute medical admission? Would they mind taking part in a process which associates discussion of resuscitation in the event of their death, and a significant student input? (Although the article does not make clear the extent to which students would be involved in resuscitation discussions). Explicitly telling patients that they are being asked to enrol in a study is essential, likewise student involvement in studies of this sort is also admirable, but unfortunately both factors might have discouraged patients from participating in a resuscitation discussion. It is also noteworthy that seven of the patients who could, potentially, have been involved in a resuscitation discussion were not because of reluctance on the part of the family. Whilst doctors might concede to family wishes in the decision whether or not to enrol a patient in a study, their wishes may be respectfully overruled when it comes to deciding to hold discussions about resuscitation with a patient. For these reasons, whilst a proportion of patients are clearly unhappy discussing resuscitation during the first 24 hours of admission, the quoted figure of 30% may not be justified from their data, and may indeed significantly overestimate the reluctance of patients as a whole to discuss resuscitation. Benjamin Reddi Competing interests: None declared |
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