Do not attempt resuscitation. Words that seem to strike fear and panic into the majority of hospital consultants. Never have I seen such cowardice and a total lack of common sense than when I broach the topic of signing a DNAR form for a patient. Especially in the surgical department which I currently work in (And I will come on to my anecdote shortly...) As is the case with the majority of problems in the NHS, it seems to stem from the arising culture and trendiness of complaints... I haven't experienced a formal complaint myself, however I understand that as well as tarnishing your reputation, it also involves lots of time staking paperwork and is an extremely tedious process, something no one really has the time for. DNAR is something I am passionate about. Having worked in acute medicine and geriatrics, and attended countless resuscitation attempts of 90+ year old nursing home residents, with end stage renal/heart failure, who have had the decision made that they aren't for escalation to HDU/ITU, however are for resuscitation.. I feel angered when these situations aren't dealt with adequately. I mean what do these consultants think happens after a resuscitation? In the very unlikely situation that these patients do come round, do they think we offer them a cup of tea and place them in a bed nearer the nurses station for observation... They don't seem to be aware of the obvious need to be moved to HDU/ITU post arrest. The decision to not escalate a patient surely comes hand in hand with the DNAR discussion? Or does that make far too much sense for the medical world? A situation arose recently which has angered me beyond belief and led to me whinging at you all in this post. This may be a slow starter but I need to set the scene. So, we have a 60 something year old lady on the ward who had a bowel perforation, which we are treating conservatively due to co-morbidities and anaesthetics saying she isn't fit for a GA. She also happens to have breast Ca with metastases to her brain and multiple others places in her body. She was of the understanding that the Ca was under control and she didn't need any more chemo for now, she commented often that she "has many years left in her and the Ca isn't life threatening." Anyway, as I usually do, I brought up the sensible option of a DNAR for this lady, given we weren't going to operate on the perforation and it having the potential to be life threatening. The consultant (as he always does) tried to dismiss my comment, then tried to bat it on to the registrar for them to have the discussion (who wasn't actually at work that week), then eventually was cornered into discussing this with her. I have never seen such an awful discussion in my life. He essentially said "if your heart was to stop, would you want us to try and bring you back?", to which the patient obviously said "yes...". He then looked to me and said "document that we have had this discussion and she would like to be resuscitated"...... Obviously in front of the patient I couldn't say anything to this, and once we had left the room I wasn't really sure what to say either. He hadn't explained the trauma of resus, the fact that for her it almost certainly wouldn't be of benefit, he didn't explain the long ITU stays that are needed even if these things are successful... I said "But if she arrests as a result of her perforation, and we aren't going to fix the perforation, then obviously resuscitation will never be successful...", to this he replied (I quote directly) "We both know that, but if she wants a few 'pumps' to keep her and the family happy then why not". My mouth hit the floor, I didn't even have a response for this stupidity, the discussion was already getting quite tense as I continued to question him and eventually I gave up. He would not accept that DNAR decisions are medical decisions, NOT patient decisions. We have to discuss it, but it should have been put as facts and the patient educated rather than giving her a decision with no information to base it on. I wonder why they don't teach us how to deal with these dilemmas at medical school?! This is only the beginning of an absolute farce of a story (I've changed certain details slightly to avoid any recognition of the patient). So this poor lady woke up in the middle of the night and couldn't move her right side. She had a CT (we did a full body to assess the Ca while she was there) which showed a sub dural haematoma (her husband tells us she had a fall before coming into hospital) as well as extreme Ca disease progression. The mets in her brain had doubled in size and she now also had bone and lung mets. Discussion was had in a MDT and it was decided that she wasn't for further treatment as her prognosis is less than 3 months, and she needs fast tracking home (essentially to be kept comfortable and die as peacefully as possible) Now, if this isn't a situation for a DNAR to be signed, I'm not quite sure what is. So I asked the consultant if he would meet with the family to explain these new findings (as they all think the Ca is under control). He said "I'm a surgeon not an oncologist, this is not my job, I think you can handle it yourself"... Which is fine, as I personally would much rather my family member received such awful news from myself rather than an emotionless scalpel, however the DNAR discussion needed to be revisited, and seen as he had decided she was for resus, he now needs to be the one to revisit and sign it.. And I think the most senior member of the team should be the one to do something like this anyway. To cut a long story short, this was a week ago, and she is still for resuscitation and the consultant still hasn't had a discussion with her. We are trying to fast track her home, but she doesn't understand what that means, or why we are doing it. I have said "we can't send her home to die, whilst she is still of the understanding that she is for resus and has "years left in her", she will bounce straight back to the hospital." To which he replies "we will just organise for her to be seen in oncology clinic so they can explain everything to her"... I have been pulling my hair out, it is so frustrating being so junior, having the most common sense, yet not being able to apply any of it. I wish I'd never asked him to speak to her and I'd just done it myself, as he is now maintaining that as she wants resuscitation, we can't go against her wishes. So I'm now in a situation where I cant under cut him and make a completely different plan.. Even though I know his plan is ridiculous. She made that decision when she thought she had "years left in her". Why does this not make complete sense to him? Why is the most senior person on my team about as bright as a pickled egg? It baffles me beyond belief and I pray I will never get to the stage where I'm so scared of complaints that all common sense and care for the patient goes out of the window.
