This is a follow-up to Dr Aroras’ earlier blog about the recent legislations surrounding Do Not Resuscitate [DNR] orders. Dr Suthahar, who is a final year geriatric registrar, reflects on the immediate impact of the legislation on the wards and the acute general take.
They say change comes slowly to the NHS… Think of the time it takes for the latest NICE guidance, CQUINs, newest drug or quality measures to filter down to the frontlines of clinical work. However in one stroke Lord Dyson in his landmark ruling on DNR orders and the legal necessity to communicate the DNR order to the patient or family members, has effectively changed clinical practice overnight.
The change was very easily noticeable the morning after. On the morning rounds, my consultant declined to complete DNR forms unless they have been discussed with the family (or patient) first. This was a similar situation on the post-take round and the following weekend on-call. Unless family were informed of the decision, no-one wanted to complete a DNR form. This practice filtered down to the registrars and by rapid osmosis soon to the junior doctors. Now, it is common for even the frailest patients to journey via the A/E to Acute Medical Unit and finally the geriatric ward without any ceilings of treatment being set.
The ruling in itself provides clarity to a sensitive and delicate area of medicine. It makes perfect sense for the patient or family to be informed of an important decision in their clinical treatment. However, by making it a legal requirement, it raises tricky problems as these are not discussions that can always be had when the patient first enters the hospital for a wide variety of reasons:- it maybe 2 o’clock in the morning, the patient may be too ill or delirious, family may live a very long way away, NOK may be unreachable at the time. Neither can this decision be easily communicated over the phone.
As the medical registrar on call, you are generally the first senior doctor that reviews patients being admitted to hospitals. Pre-Dyson’s law, the medical registrar usually would prompt decisions about ceilings of treatment and DNR orders (as generally they were the most senior doctors on site out-of-hours). Where possible all decisions were discussed with patients or their families. Sometimes if it was deemed too distressing a best interest decision was taken. Post-Dyson from my own recent experiences and also from talking to fellow colleagues, DNR forms are now viewed with trepidation and fear especially, in instances when family members/NOK are not contactable, and patients themselves are incapacitated by illness (this reflects a significant proportion of older patients being admitted to hospital). Do you really want to take ‘an act of Good faith’/best interest decision and sign the DNR form only to find this challenged by family at a later stage for lack of communication? Legal implications could very soon mean loss of training number, license to practise and the mortgage to the house.
The pendulum has swung the other way and now it seems easier to just not complete a DNR order (“…..avoid the hassle….”). With all the present pressures of increased admissions, time, beds and push to discharge, it is easy to take the view of just avoiding the DNR topic altogether. The view in community and of GPs would be interesting. Would they be increasingly reluctant to complete a DNR? The solution to the problem is easy. Being proactive (broaching DNR discussions in clinics – early on in progressive diseases such as COPD, renal failure, Parkinson’s, heart failure), Advance Care Planning, establishing End of Life registers (accessible across the UK) and Advance Decisions by patients. However, these solutions require changes to the way we work… and change unfortunately comes slowly to the NHS. How do we enforce change quicker? Perhaps we could take it to the High Court…