Views & Reviews Personal view

AND (“Allow natural death”)—could it make a difference?

BMJ 2009; 339 doi: (Published 08 July 2009) Cite this as: BMJ 2009;339:b2762
  1. Rachel McCoubrie, consultant in palliative medicine, Bristol Haematology and Oncology Centre
  1. Rachel.mccoubrie{at}

    Throughout our medical careers most of us will be involved in DNAR (“Do not attempt resuscitation”) discussions with patients and their families. Last year I found myself, for the first time, on the other side of the discussion. My father had longstanding polycythaemia, which transformed into myelofibrosis. In the last month of his life he was admitted to hospital with epistaxis then again, a week later, with deep vein thrombosis and pulmonary embolus. His physician, faced with the dilemma of how to manage a patient with low platelets, proved thromboses, and daily nose bleeds, decided, in discussion with my father and us, on treatment with low dose, low molecular weight heparin.

    Two weeks later he was admitted with a massive retroperitoneal bleed. He was not fit for surgery, and admission to a high dependency unit was judged to be inappropriate. He was managed with blood and platelet transfusions, fresh frozen plasma, and Gelofusine to try to normalise his blood pressure. However, he remained hypotensive and became anuric, and his …

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