Soft task hard to do: the challenge of Do Not Resuscitate discussions

A soft task hard to doThe challenge of resuscitation

discussions

Dr Philip BerryConsultant Hepatologist,

Gastroenterologist and General Physician

@philaberry www.illusionsofautonomy.wordpress.com

Resuscitation

• Life saving• Highly symbolic: the final fight against death• Peter Safar, 1956 "save the hearts and brains of

those too young to die."• …but not very effective in some groups– 12.2% >90 yrs survive to discharge1

– For every survivor >80yrs, need to do CPR on 292

• Default

1. Ehlenbach et al NEJM 20092. Paniagua et al Cardiology 2002

National Confidential Enquiry into Patient Outcome and Death

National Confidential Enquiry into Patient Outcome and Death

Bertie Leigh

How to do a DNAR discussion

• 6 step model

Von Gunten, 2001

Setti

ng

Setti

ng

Understanding

Setti

ng

Understanding

Expectation

Setti

ng

Understanding

ExpectationD

iscussion

Setti

ng

Understanding

ExpectationD

iscussionRespond

Setti

ng

Understanding

ExpectationD

iscussionRespond

Implement

Setti

ng

Understanding

ExpectationD

iscussion

Respond

Implement

`

Barriers

`

Situation

`

Situation

Behaviour

`

Situation

Behaviour

Patient response

`

Space and Time ‘Hard’ tasks

Nature of emergency: uncertainty

Nature of emergency: incapacity

Space and Time

Space and Time

Space and Time

‘Hard’ tasks

‘Hard’ tasksHe’s shocked,

give a litre of

fluid

Do an LP

Order an

urgent CTCall the GP,

find out what

drugs she’s on

Chat to the family about DNAR

‘Hard’ tasks

He’s shocked, give a litre of fluid

Do an LP

Order an urgent CT

Call the GP, find out what drugs she’s on

…and chat to the family about DNAR

6.30PM

Nature of emergency: incapacity

CapacityNo

Capacity

He must consider, so far as is reasonably ascertainable—(a) the person's past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity),(b) the beliefs and values that would be likely to influence his decision if he had capacity, and(c) the other factors that he would be likely to consider if he were able to do so

MCA 2005 Section 4

CapacityNo

Capacity

Next of kinFamilyFriendsCarers

GP

IMCA?

Nature of emergency: uncertainty

†

†

Admission

Oblique phrases: clues to uncertainty

• ‘Cautious’• ‘Serious’• ‘Worrying’• ‘Guarded’• ‘Day at a time’

- Preparing the ground -

Oblique phrases

• ‘Cautious’• ‘Serious’• ‘Worrying’• ‘Guarded’• ‘Day at a time’

…indicating death is possible

Oblique phrases

• ‘Cautious’• ‘Serious’• ‘Worrying’• ‘Guarded’• ‘Day at a time’

…indicating death is possible

† ∴ a trigger to consider discussion

Space and Time ‘Hard’ tasks

Nature of emergency: uncertainty

Nature of emergency: incapacity

Dropping a gear

Normalisation

Defensiveness

Defensiveness

Dropping a gear

Active Tx

PalliationURGENCY/PRIORITY

DNAR

Active Tx

PalliationURGENCY/PRIORITYA tendency to equate DNAR

with palliation…

And a subsequent lessening of the sense of urgency

DNARActive Tx

Palliation

But DNAR should probably be considered earlier in the natural history…

…when the patient is more able to engage

DNAR

Active Tx

Palliation

DNAR

Active Tx

Palliation

DNAR

Active Tx

Palliation

!

Perhaps even on admission…

DNAR

Active Tx

Palliation

!

DNAR = No active Tx

Normalisation

(Frequency of death)

(Superficial involvement) Normalisation

Normalisation

(Frequency of death)

(Superficial involvement)

(Bureaucracy)

(Beds)

Brutalisation( ) Ref: media criticism around LCP

Normalisation

(Frequency of death)

(Superficial involvement)

(Bureaucracy)

(Beds)

Brutalisation( )

Deprioritisation

?

Only by talking, listening and reflecting on the patient’s predicament…

EMPATHY

…will a 3 dimensional image form, and the need to make appropriate plans become clear.

At last…

…but there is another barrier…

Physiciandiscomfort !

Important, but part of professional life…

And we need to be able to overcome it.

SensitivityGentlenessKindness

StatisticsLikelihood

Reassurance

The words… (suggestion only!)

• “Mrs ____, I’d like to discuss something with you. It may sound rather pessimistic and serious, but it’s important that we talk about it. I need to ask you about what we should do if your heart were to suddenly stop.”

• “As you probably know, for some patients we try to restart the heart with compressions on the chest and electric shocks, but we know that this doesn’t work very well as you become more frail, or if you already have problems with the heart or the lungs.”

• “It’s important that we understand your feelings about this, and that you know what we think. Then we can write it in the notes so that other doctors know what to do if something like that were to happen.”

Responses

• Bewilderment:“Oh…I’ve never really thought about that before doctor. I didn’t think I was that unwell.”

Responses

• Defiance (of mortality):“Well I want to live as long as I can. I don’t want to give up that easily.”

Responses

• Fatalism:“Whatever happens, it’s meant to be…”

Responses

• The ‘old fashioned’ (paternalistic mode):“Do whatever you think is best…”

Responses

• The sure:“No. No, I definitely wouldn’t want that, I’ve had quite enough time.”

Responses

• And the hesitant:“OK doctor, but I would like to discuss it with my family. They would want to be involved.”

The ‘Slow code’

“A leading textbook calls slow codes ‘dishonest, crass dissimulation, and unethical.’”

‘…deplorable, dishonest and inconsistent with established ethical principles.’

The ‘Slow code’

“Nevertheless, we believe that slow codes may be appropriate and ethically defensible in situations in which cardiopulmonary resuscitation (CPR) is likely to be ineffective, the family decision makers understand and accept that death is inevitable, and those family members cannot bring themselves to consent or even assent to a do-not-resuscitate (DNR) order.”

Scenario

• A 91 year old lady is admitted to hospital with symptoms of urinary tract infection and significant kidney dysfunction.

• Known aortic valve disease (not for surgery) • Confused, temporarily, by the sepsis. Lacking

capacity.

Scenario

• The consultant decides that CPR would definitely be ineffective, and speaks with the family.

• They are shocked, uncertain, afraid…and resistant to a DNAR decision; ‘she’d wouldn’t want to give up…’

• What should the consultant do tonight?

Decision

A

Re-engage with family tomorrow

Decision

A B

Complete a DNAR form anyway

Re-engage with family tomorrow

A

Crash call

Outcomes (in the event of unexpected arrest at 0200hrs)

A

Crash call: rapid abandonment by arrest team

Outcomes (in the event of unexpected arrest at 0200hrs)

Outcomes (in the event of arrest)

A B

Natural death

Crash call: rapid abandonment by arrest team

Morality

A B

Duplicitous?Moral cowardice?

Brave?Risking censure?

- Inevitable?-- Justifiable? -

?

Thank you