Do Not Resuscitate or DNR is a measure taken by doctors after discussion with a dying patient and their family that, due to the suffering and terminal nature of the disease, they will not attempt resuscitation. But we now know that DNR is a confusing misnomer. This is why the term DNACPR was introduced. The reason is that DNR means (or meant) just that: DNR. Many often go at a tangent with the feeling that just because someone is on a DNR order they should not be given any other extraordinary measure, such as blood transfusion. But that is just the point. In medicine what seems like common sense to a lay person, or even another health care professional, is not. If a person is terminal and after discussion it is deemed that Cardiopulmonary resuscitation would be too cumbersome, then it can be avoided. This does not mean that if the patient needs a ventilator or a blood transfusion, it should not be given.
I say this because many students (both from the health professionals and other university course) bring cases such as a 94-year-old man who was on a DNR order but then needed a blood transfusion. This tends to surprise some – why transfuse a 94-year-old person who is in bed, or, someone who may die soon. Certainly, if death is imminent within the next few days, it is one matter, but if it is imminent within a few months it is quite another thing. Having said this, grumbling and mumbling about these decisions is futile, but I am happy they bring up these case studies for discussion and it is the result of not having a protocol on end of life for years on end. Someone, somewhere, somehow, seems to block it. Health professionals can find more meaning in their work, as I do myself, by trying to address these issues through bureaucracy and management who may think that something is not broken and therefore does not need fixing.
When one is approaching end of life one has a right to palliative care, which includes certain treatment even if it is not meant to prolong life indefinitely or in some way provides relief. Therefore, an antibiotic may be given not so much as to attempt a cure of a chest infection or a urinary tract infection, but simply to relieve symptoms. This is true palliative care. One does not attempt resuscitation simply because it will not produce any benefit, at least in the palliative sense. What sense does it make to create broken ribs and discomfort, only to wait for another time for a repeat defibrillation (shock)? There is a difference between killing and allowing one to die in peace. No doctor in his right senses would continue to perform Cardiopulmonary resuscitation (CPR) indefinitely and repeatedly as jumping to a shock and then eventually dying is certainly not what one would consider a good death. And yes, the elderly, even if not close to death yet, do need palliative care and an advanced care plan, which may or may not include not resuscitating, but includes other things.
CPR has its place. Former chair of the ethics committee of the Royal College of Physicians of London says it elegantly: “At best CPR is the gift of life: chest compressions, ventilation, intravenous medication and defibrillation followed by years of productive and fulfilled being. At its worst, it offers a scenario of vomit, blood and urine, then a confused brain-damaged twilight, breathlessness from a failing ventricle (for example, a failing heart), pain from rib fractures, until expiring in thrall to the full panoply of intensive care or forgotten in the long darkness of the persistent vegetative state. No humane doctor would consider this a good death, now would any poet, priest, musician or novelist use images of CPR to represent the Good Death, rather the images are more likely to be those of the factory: death in the industrial age.” I cannot tire reading this passage repeatedly. John Saunders is not only a good friend but an extremely good doctor – not only as a specialist but as “good” in humanely good.
Some may remember how the Liverpool Care Pathway – a palliative care pathway to bring palliative care to those who cannot afford hospice care – was dubbed by a Maltese physician working in the UK as a Euthanasia Pathway – as that is what, in fact, it turned out to be. Instead of following a palliation path removing what is unnecessary and introducing measures to make the person more comfortable, it simply became a tick-box to remove items, we mentioned in the beginning of this column. That is outright, albeit unknowingly, passive euthanasia, to which people, rightly so, protested against. Subsequent measures changed this and the investigative document One chance to get it right, means that with each and every patient we indeed do have only that one chance to get it right with them.
The Mater Dei Anaesthesia members have drawn a DNACPR document. I am not sure at what stage this has arrived. But I wish to comment on the new name mentioned above for DNR. DNACPR means Do not attempt cardiopulmonary resuscitation. This is more explicit in its meaning. It is only CPR that is being recommended not to be attempted. This does not mean that we may not remove other measures, which would be uncomfortable or simply prolonging the agony of a dying patient. Blood transfusion may be one of them. But this is a separate decision. Those who think that just because someone is on a DNACPR order should not be given other palliative or even, in some instances, life prolonging treatment, are simply not understanding the situation and should not be close to people who need help at the end of their lives. This is a clinical decision, just as there are decisions which only the architect has to make and take responsibility for, and not the builder. Those who came in contact with the builders may know how much they, albeit through experience, may not agree with an architect. The architect calculates the material weight and volume of a beam – the builder does not. He may estimate it through past experience but he may easily forget that it is not only the building you have to take into account. In building a library you take into account the weight of the books, the shelves and the people.
As the father of modern medicine William Osler said, doing medicine without books is sailing an unchartered sea; doing medicine without patients is not going to sea at all. And each patient is different. Some decisions are better left to the doctor to deal with. He/she will of course take other opinions, especially the family’s views. But at the end of the day it is he/she who carries, not only the legal responsibility but the responsibility that we all wish to have – a good death.
Pierre Mallia is Professor of Family Medicine and Patients’ Rights and teaches at the University of Malta. He chairs the Bioethics Research Programme of the Faculty of Medicine and Surgery. He also chairs the Bioethics Consultative Committee.
This article is his personal opinion and does not represent the opinion of any committee or Board he serves on.
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