The death of DNR

At our hospital, we have a policy that discussion about resuscitation options be discussed with all applicable hospitalized adult patients. This need to be documented in the patient’s chart, on a special “Level of Treatment form” (see attachment) at the time of admission for patients admitted to intensive care unit, and within 48-hours for patients admitted to medical or surgical wards. The hospital had a 3 page document that I have modified to one page that is liked by all health care providers, including the nursing and medical staff.

Figure

If the attending physician feels that the discussion about resuscitation is not required for a particular patient during hospitalization then the NO option is selected in section 1 and the form is placed in the patient’s chart, and if the discussion is required then section 2 and 3 are completed. This form remains valid during hospitalization unless revoked when a new form is completed.

Competing interests:
None declared

We agree with several other correspondents that the term “allow
natural death” (AND) is too vague and imprecise and it could well alarm
many of our patients, especially those who might survive their current
medical episode if they do not have a cardio-pulmonary arrest. For example
a patient with advanced COPD who would not be expected to survive
ventilation on ICU will often benefit from non-invasive ventilation on the
respiratory ward. This patient would not benefit from attempted CPR but
might be justly alarmed to see the words “allow natural death” written at
the end of the bed. We also agree that “DNR” is an inappropriate term,
partly because it implies wrongly that successful resuscitation
(resurrection) would be likely and partly because many people would
consider that other life-saving treatments such as IV fluids and
antibiotics are covered by the term “resuscitation” and therefore
prohibited by a “DNR” order. We currently use the DNA-CPR abbreviation at
Salford Royal University Hospital to make it clear that it is only CPR
that will be withheld from patients and our DNA-CPR printout specifically
states that no other intervention is covered by the order.

However, we agree with Sokol and with the previous respondents that a
positive, patient-centred order is preferable to a negative order that
appears to prohibit some aspect of treatment. We are essentially trying to
protect vulnerable patients from an inappropriate, serious and undignified
physical assault (cardiac compression, electric shocks etc) at the moment
of their death or just afterwards. We would therefore suggest a new
acronym of PFA-CPR (protect from attempted CPR) which has the virtue of
being similar to the familiar “DNA-CPR” order with the important
distinction that it is clear that the intent of the order is to protect
the patient from loss of dignity and potential harm rather than to deny
the patient an (inappropriate) intervention.

Competing interests:
None declared

I agree that a DNAR decision does not relate to any of the many other
important aspects of care planning that should take place other than CPR.
However, it seems odd to me to single out one treatment modality (CPR) for
discussion with patients and family when this is an opportunity to make a
more holistic plan which , in my experience, is less traumatic for the
patient.
Other medical problems can also require very immediate decision making -
for instance dealing with acute respiratory failure.
Additionally, it is clear to me that a DNR form is often misinterpreted as
a "Not for Treatment" order - to unpick this will require a monumental
teaching effort.

Competing interests:
None declared

We have developed a system for children with severe neurodisability
and life limiting or life threatening conditions to have 'Personal
Resuscitation Plans' (PRPs) instead of 'Do Not Resuscitate' orders (DNRs).

We agree with the author that we should be using terminology which
describes a more positive approach at the end of life, but 'Allow a
Natural Death'(AND) still implies 'do nothing' whilst a personal
resuscitation plan is a medical care plan stipulating best care in the
event of deterioration, whether this is sudden or more gradual.

Children's nurses said to us that they needed clear information on
what interventions were appropriate when a particular child deteriorates,
not just an instruction not to call the 'arrest team'.

We use a template with a list of increasingly invasive interventions
to discuss with parents, and where possible the young person, to agree the
most appropriate treatment. The emphasis is on what will be beneficial and
what care will be given in an emergency rather than what won't be done.
Also the plan can change over time as the child's condition deteriorates
and certain interventions are no longer appropriate and the family is
ready to accept that.

Approaching a family to draw up what they can see is a useful
emergency care plan is much easier than approaching them with a DNR form.

An audit of the system showed that 14 of the 19 children with PRPs
would have no more invasive treatment than suction, oxygen and a trial of
bag and mask ventilation in the event of an acute collapse. 50% of
families found it difficult and upsetting to complete a PRP but all would
recommend it to other families. Comments included 'it's important to plan
ahead and for eveyone to know what to do,' 'it gives me peace of mind,
there will be no misunderstandings about his treatment,' 'it will give us
more control of the situation'. Feedback from nurses is that PRPs are
empowering and reassuring when they are managing a dying child whether at
home or in hospital.

Competing interests:
None declared