Guidelines ignored on resuscitation decisions
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7209.536b (Published 28 August 1999) Cite this as: BMJ 1999;319:536
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Dear Sir,
I was quite amazed that such a low percentage of consultant's are involved
in Do Not Rescuscitate decisions.
I am also an ALS Instructor and the UK resuscitation guidelines are very
clear.
The overall responsibility for resuscitation rests with the
consultant only (or his senior registrar in his abscence); however the
appropriatness of resuscitation or not may be raised by the:
patient,relatives or close friends, GP, medical or nursing staff.
DNR orders should be made as soon as a diagnosis and prognosis is
made,(or if a bona fide advanced directive is made), and not at the time
of a crisis. The DNR order should be signed by the consultant and
regularly reviewed in both the medical and nursing notes. It is important
to realise that a DNR order is not static, but is in fact a dynamic
entity, that can be changed by the consultant should prognosis or the
patient's situation change. Where possible DNR orders should include prior
consent of the patient, explanation and justification.
Another important issue to mention is that DNR orders apply only to
resuscitaion and should not therefore impart a substandard or "relaxed"
degree of general medical/nursing care to these patients who in fact
should be given more delicate and empathic care than normal.
A final message is IF IN ANY DOUBT-RESUSCITATE. It may well be one of
us lying in that bed one day!
Competing interests: No competing interests
Whilst employed as a Resuscitation Training Officer in a London
teaching hospital, the Resuscitation Committee updated the present "Not
for CPR" guidelines using the BMA/RCN/RC(UK)statement as a framework. It
was successfully integrated into the Trust after 1 years hard deliberation
and indeed published in a peer reviewed, international journal. The
documentation of the decision making process was specifically targeted as
we found it was extremley poor within the Trust. Throughout the literature
we reviewed, this was also apparent in many other hospitals/trusts and was
deemed to be unacceptable by our Resuscitation Committee for our policy.
We believed we had reached a user friendly document for all to use and
felt that both medical & nursing staff would openly embrace the new
policy. However following a review of the communication process it was
disappointing to find that only one third of all the consultants even
acknowleged the fact that there was a new policy or indeed that they were
accountable & responsible for the documentation, despite the
documentation form having strong support from the consultants committee.
It appeared that the senior medical staff in this instance were reluctant
or indeed unprepared for the responsibilty that lay with them in making
and taking, "Not for CPR" decisions. This is an area that is long overdue
its importance in todays healthcare and needs to be tackled by all Trusts
medical and nursing staff head on. It may make staff feel uncomfortable
addressing the issues surrounding "Not for CPR" but as professionals, are
we not in self denial of a process that could be constructive for all
concerned, and give the patient the full care they need and deserve? After
all, we may have someone making such decisions about us in the future.
Competing interests: No competing interests
Flogging dead horses?
Sir, I was not surprised to see this report. I have worked in several
hospitals on acute medical wards and often seen fudged resuscitation
decisions. I believe that the decision on resuscitation should,as with any
treatment, be made by the patient first. If the patient is unable or too
ill the decision should be made in consultation with the nearest relatives
available.The doctor's decision should be based on information from these
two sources. In the rush of an acute admission there may not be time to
gather this information. An advance directive would be useful here.
Ideally all the information about a patient would be seen by the
admitting consultant quickly and a resuscitation decision made quickly.
However often patients are admitted in the night or not seen until later
on by the consultant. In these circumstances the medical s.h.o. or
registrar on call will have to make a decision about resuscitation, either
(and preferably) before or during a crash call. One of the key decisions
to be made is the point at which to stop curative medicine and move to a
palliative approach towards a dying patient. I suspect this decision is
frequently made but often not documented. Nurses in particular find this
lack of clarity stressful. I also found this a stressful part of medicine.
I believe that a blanket prescription of everyone being for
resuscitation unless the consultant says otherwise is a recipe for futile,
unwarranted and unkind cardiac arrest calls on patients who are dying and
should be allowed to die in peace without lots of young doctors performing
heroic but pointless cardiac resuscitation. To paraphrase a French
journalist watching the charge of the Light Brigade, "It's magnificent but
it isn't medicine"
The medical wards of hospitals admit the oldest and sickest people in
our community. Whilst I am in favour of treating as many people as
possible there comes a time for letting people go gently and I hope that
if I am in that state that my doctors (whatever grade they are) will have
the courage to let me die peacefully, without useless resuscitation.
attempts.
Competing interests: No competing interests