The orders – which record an advance decision that a patient\’s life should not be saved if their heart stops – are routinely being applied without the knowledge of the patient or their relatives.
On one ward, one-third of DNR orders were issued without consultation with the patient or their family, according to the NHS\’s own records. At another hospital, junior doctors freely admitted that the forms were filled out by medical teams without the involvement of patients or relatives.
When you\’ve a system that insists that the system knows best, that individual choice couldn\’t possibly have anything useful to add to what the system knows is best for each and all, it\’s just not that surprising that it\’s the system that starts making choices about life and death, is it?
Why is this even supposed to a bad thing? Sure, if they were being issued *against the patient’s expressed wishes*, it’d be a problem, but they aren’t.
If you want to be resuscitated no matter how grim your prognosis, get the doctor to record that in your notes. If you want to not be resuscitated pretty much at all, get the doctor to record that in your notes. If you don’t subscribe to either of those viewpoints, then let the doctor decide. Which is what’s happening here.
john b – “Why is this even supposed to a bad thing?”
I can think of several reasons. Because it is not transparent. Suppose I was an NHS doctor and I did not like, say, Jews. I could write DNR on the charts of anyone with a vaguely Yiddish sounding name. I would really not like them. I would hope you would think this was a bad thing.
Because it is not the job of the doctors to decide who lives and who dies. It is their job to do what we pay them for – to save lives.
Because it violates medical ethics to be able to do something, and to refuse to do it. It is often a crime in fact.
Those are just off the top of my head. I am sure there are more.
“Sure, if they were being issued *against the patient’s expressed wishes*, it’d be a problem, but they aren’t.”
But John, no-one’s asking the patients or their relatives. So, they don’t KNOW their expressed wishes…
John, the default should be resuscitation not being left to die. If doctors don’t think that resuscitation is really practical it is up to them to raise with the patient and/or relatives.
The alternative is that we have to remind doctors that we want to live every time we go near the NHS, perhaps carrying card that says please try to keep me alive.
Since when does someone have to ask permission to remain alive? Since when does one have to, effectively, re-apply for NHS treatment? And at such a critical time?
This is an example of why the NHS is systemically dysfunctional and why the ideology and blinkered support of those who worship it is so dangerous.
If a private hospital was doing this, the state would be filing murder charges, shutting it down, arresting the board of governors. No. The state, writer and enforcer of the law, gives itself and its henchmen a by.
And people wonder why some of us are against default harvesting of organs without permission.
Now, I do believe we do have Fabians and other poisonous socialists and authoritarians who consider the population as chattel, as milk-cows or brood mares subconsciously, but this is beginning to take things into the realm of conscious acts.
Ps his views are why people like John B should “step away from teh vehicle” of government. It exhibits an utter contempt for not only the rights of the individual, but what must be the limits of State power.
But John, no-one’s asking the patients or their relatives. So, they don’t KNOW their expressed wishes…
If you don’t proactively express your wishes, why in *fuck* would you expect anyone to pay attention to them? Well, maybe your spouse (“YOU SHOULD HAVE KNOWN THAT’S WHAT I WANTED”), but not external organisations, whether governmental or not.
If you’re getting DNRd the chances are it’s not possible to have a lucid conversation with you about your wishes, at any time. The practice really is only needed because of technology – constant heart monitoring, resiprators and so on, plus round-the-clock nursing staff trained in the use of high tech cardiorespiratory rescuscitation equipment. 50 years ago all of these people would have died in their sleep. Nowadays, very few of them (DNRs that is – not those who are not DNRs) will ever leave hospital – we really are talking about people on the brink of death anyway.
It would be a scandal if an otherwise healthy 30 year-old was DNRd, but of course it is going to happen to people in the last stages of terminal cancer, people to whom dying this week might be preferable to next week.
I should add, what the fuck does the family have to do with it? They will be the ones deciding in your stead in 95% of cases and mostly they will want to keep you hanging on. This is as much an intrusion into your rights as a doctor deciding the other way. Unfortunately the illucid terminally ill, like babies, being unable to communicate their wishes do have fewer rights than the rest of us. I’m not sure you obtain the right to an intervention just because it is now available, especially when no one really stands to benefit from its administration.
Its murder, pure and simple.
Your faith is very touching, JamesV.
Last October my father-in-law had pneumonia and a junior doctor decided that he should be DNRd because he did not have a high quality of life. Apparently being surrounded by a large family with many granchildren who visit you every day doesn’t count as a life. MrsBud, a social worker, phoned him and insisted that he be resuscitated and that their conversation be recorded in his notes. She then flew halfway around the world to look after him. A year later he is back home, lucid and again very much in the bosom of his loving family.
Being a skilled doctor does not mean you are good at forming value judgements. I’d prefer my family made the call and if DNR was appropriate I’m sure they’d make the decision out of love, not to get their hands on my money.
I suggest getting “resuscitate at all costs” tattooed on your chest.
“It’s murder, pure and simple”
That there are fcuk-ups & communication issues with DNR orders, there can be no doubt – & there is no excuse for not involving next-of-kin, where possible. But some of the hysteria on here ignores reality, as anybody who has broken the ribs (you will hear & feel it) of a little old lady during futile CPR will understand. Death is death.
There is a lot of nonsense spoken about DNR orders.
Point 1 would be that if you are requiring CPR you are already dead, so it would be difficult to murder you.
Point 2 would be that the heart stopping is part of the process of death – it happens to everyone when they die.
Point 3 would be that it is a medical treatment like any other – it works in some cases but not in others. The overall success rate (ie survive to discharge from hospital) is in the region of 10%. There are a lot of patients for whom CPR would be entirely futile – the terminally ill and those in multi organ failure for example – no amount of resuscitation is ever going to work. It’s a general principle of law/ethics that futile treatments shouldn’t be carried out.
Point 4 is that when a patient is admitted to hospital we don’t have to have a discussion with them about how we’re not going to offer them a hip replacement/amputation/course of antibiotics/toenail clipping/every other conceivable medical intervention that wouldn’t be of benefit to them so why should it be different for CPR?
Blimey… a sensible post.
Thanks Gasman.
“If you don’t proactively express your wishes, why in *fuck* would you expect anyone to pay attention to them?”
So if you come to my house, and collapse from some injury/illness, and you didn’t expressly tell me that you wished me to call an ambulance in the event of you being taken ill, am I entitled to make my own decision as to whether I call one or not?
I don’t really understand what a ’cause of death’ is. Isn’t it always “his heart stopped, guv”?
DNR is really simple. It should only be applied to those with minimal life expectancy left for entirely natural reasons. As in, about 6 weeks, though every hospital will have its own guidelines.
It’s a treatment that was not available until relatively recently. It was a treatment that was irrelevant until we developed ICU, heart monitors, and round-the-clock nursing by highly-skilled staff who could attend a cardiac arrest within 30 seconds. You still have the problem of what to do when you have two such arrests at 3:30AM. Crash team is attending to 98-year-old great-granny, with metastatic lung cancer, and cirrhosis and kidney failure to boot. Meanwhile, 29-year-old new-dad sole breadwinner, victim of a hit-and-run, in hospital for cerebral decompression after the accident, and with a reasonable chance of pulling through and possibly even returning to a totally normal life goes into arrest. Who do you decide to save? The legally correct answer is the former, for having started to treat the former, withdrawal of potentially life-saving treatment after it has commenced can indeed be treated as murder. The morally correct answer is obviously the latter.
Until very recently, most of these people were discovered in the morning, having passed awway quietly in their sleep. We used to consider that normal until the Daily Mail started going on about death orders or whatever.
People who need rescuscitation in hospital mostly die anyway. Only a single-digit percentage live to tell the tale. It is not Casualty or ER, this is real life (and death). If you have limited resources (and CA-trained nurses at 3AM are pretty bloody scarce) you need to divert that scarce resource to where it will have the greatest beneficial effect. Deciding that an end-stage multiple organ failure patient who will almost certainly be dead within days (and that is absolutely a clinical decision) should probably be left to slip away if they go into arrest overnight, is simply efficient allocation of resources.
john b – “If you don’t proactively express your wishes, why in *fuck* would you expect anyone to pay attention to them?”
Great. Can’t wait until the next sorority girl passes out drunk in my house. I expect John B will be there to defend me at the rape trial.
7 JamesV – “If you’re getting DNRd the chances are it’s not possible to have a lucid conversation with you about your wishes, at any time.”
That may be true in most cases but it is clearly not true in all. Either way we need to discuss this. Not leave it to budding Shipmans to decide on our behalf.
“It would be a scandal if an otherwise healthy 30 year-old was DNRd”
How do you know?
“I should add, what the fuck does the family have to do with it? They will be the ones deciding in your stead in 95% of cases and mostly they will want to keep you hanging on.”
It is rare to see anyone suggest that your loved ones wanting to keep you alive is a bad thing. Thank you for that alone. The family are the only ones who have a real and on-going interest in your well being. As opposed to, say, nurses who can’t even be bothered to feed their dying patients. How many die of thirst every year now? As such they should be listened to.
“This is as much an intrusion into your rights as a doctor deciding the other way.”
You know, that’s funny. It is an intrusion into your rights to NOT be denied life saving medical treatment that you have paid for and probably want.
JamesV – “DNR is really simple. It should only be applied to those with minimal life expectancy left for entirely natural reasons.”
Should. Such an interesting word. Any evidence that it, you know, is?
“People who need rescuscitation in hospital mostly die anyway. Only a single-digit percentage live to tell the tale.”
If ever you want to see a slippery slope here it is. We have gone from saying human life is sacrosanct to saying it is only a few percent. A couple of hundred people. Not enough to get worked up about. That way Shipman lies.
“Deciding that an end-stage multiple organ failure patient who will almost certainly be dead within days (and that is absolutely a clinical decision) should probably be left to slip away if they go into arrest overnight, is simply efficient allocation of resources.”
And yet most of us recoil at the efficient allocation of resources as applied to people. As in American slavery or Work Camps across the world. For good reason.
JamesV,
Yes, doctors have to make tough choices at 3:30am and I don’t think many would blame them if they turned their attention to the 30-yo breadwinner rather than the 90-yo with organ failure.
The issue under discussion is whether or not they should be issuing DNRs without discussing it with the patient and/or his NoK when they have the opportunity.
I’m starting to wonder if some of this is because doctor’s don’t want to address the issue with the NoK given that dying appears to be a taboo subject with some people?
Great. Can’t wait until the next sorority girl passes out drunk in my house. I expect John B will be there to defend me at the rape trial.
There is no better way to show the absurdity of John B’s argument than the above quote.
No, it’s a bollocks example, because you don’t have a reasonable belief that the sorority girl in question wanted to be fucked while she was passed out (if you could establish such a reasonable belief, then it’d be the trial of the century, but I’d certainly back you up, as would the law), and nor can you demonstrate it was in her best interests to be fucked whilst she was passed out. It’d be a struggle, because we have strong evidence that almost nobody ever wants to be fucked by a stranger while unconscious.
On the other hand, the whole point of DNR orders is that doctors make them based on the patient’s best interests, not for personal thrills, and there *are* a hell of a lot of people who would rather go gently into that good night than have their ribs broken by a crash team in exchange for a few more days’ extra pain.
I’m starting to wonder if some of this is because doctor’s don’t want to address the issue with the NoK given that dying appears to be a taboo subject with some people?
I’m sure this is part of it. It relates to the discussion in the Stephen Pinker thread – doctors, being mostly maths-y stats-y sorts, struggle to communicate to soon-to-be-bereaved relatives (who are generally neither stats-y to start with nor thinking particularly straight) the message that dying peacefully now *is* less bad than dying in a few days in even more agony.
Six months before my father-in-law got pneumonia (see above), my 81 year old dad got double pneumonia and did have to be revived by the crash team. One of the other patients testified that they fought long and hard to bring him back. When we got to see him it was apparent that he was certainly not keen to go just yet and he got upset when talking about how close he’d been (as the joke goes, who wants to live to 95? Someone who’s 94). 18 months later his mobility is much reduced but he is still enjoying life. We spent some special days together when visiting this summer.
The DNR can depend on where in the country you are and on the values and outlook of the admitting doctor.
JamesV, your example is not about DNR (the crash team are working on the 98 year old), but priorities when resources are limited. One could have a field day with that, throw in a 17 year old drug addict with failing kidneys, a morbidly obese diabetic, etc. If resources are limited, we have to accept that choices will have to be made. However, doctors who do not know a patient from Adam are not best placed to assess what is in their best interests and form judgements on quality of life. In my father-in-law’s case, the doctor seemed quite determined that he should be DNRd, initially refusing to talk to my wife.
john b – “No, it’s a bollocks example, because you don’t have a reasonable belief that the sorority girl in question wanted to be fucked while she was passed out (if you could establish such a reasonable belief, then it’d be the trial of the century, but I’d certainly back you up, as would the law), and nor can you demonstrate it was in her best interests to be fucked whilst she was passed out.”
Actually it would not be that hard at all. I am just really good in bed. Easy to demonstrate. It is also hard to prove that dying from neglect is in anyone else’s best interest either. And the idea it is in anyone’s best interests to be left to die of neglect is an interesting claim. On what basis do you make it? Except, I assume, your own personal opinion about what you might want in that situation. Which you are not.
“It’d be a struggle, because we have strong evidence that almost nobody ever wants to be fucked by a stranger while unconscious.”
We have well little evidence people want to die either. However people do consent to both.
“On the other hand, the whole point of DNR orders is that doctors make them based on the patient’s best interests, not for personal thrills”
Sorry but no. We have not had one sensible comment so far based on the patients best interests. We have had efficient use of medical resources for instance. But not exactly how a grown person being denied care without their own or their family’s consent amounts to their best interests. You are shifting the goal posts.
What is more you have no idea why doctors make the decisions they make. And there is no denying that killing people does give many people a thrill. It is hard to untangle people’s motivations so this is probably a case where it is better to avoid the situation in the first place.
“and there *are* a hell of a lot of people who would rather go gently into that good night than have their ribs broken by a crash team in exchange for a few more days’ extra pain.”
There may be. If so it is no problem simply to ask. Which these doctors are conspicuously not doing. Not that the choice is as simple as you make out. Someone may struggle like hell to die in the first place, and yet they might go quietly the second time. Especially if they are drugged up to their eyeballs in morphine for the ribs. You don’t know. You assume.
@gasman are you an anaethsetist or is the handle in reference to something more historical? Either way I don’t want you anywhere near me or mine.
@lost_nurse you are in the wrong profession. Abbatoirs are always recruiting.
@john_b: Glad to know you are happy to let a random stranger take the decision for you, in the confidence that technical knowledge is sufficient! Presumably you have no other interest in life than whether you have “got your health”. Some of us do though.
Philospohically it’s also the price one pays when one hands total responsibility for healthcare over to the government.
In return for the ease and security, the public hands over its rights.
Some people on here have got decidedly Hollywood notions of what can be achieved by CPR. It’s messy and brutal, with generally poor outcomes.
Communication is an issue, granted. Even if intervention is clearly futile, it’s sometimes necessary to (gently) explain why the crash team won’t be piling in.
Ben: Yes I am an a anaesthetist, which means I’m the one who gets to say “stop” a lot at cardiac arrest calls in the middle of the night, because none of the team looking after the patient have thought to put them DNAR despite the normal collection of great age, multiple co-morbidities and a pre-existing “not for ICU” decision.
Communication is more of an issue than anything else with this and mainly that CPR doesn’t work as well as TV/Hollywood would have you believe, although also communication of the decision to the family could improve matters in some cases. Having said that, we don’t seem to find any need to tell patients a big long list of all the unneccessary or futile treatments we won’t be giving them every day, so why this?
Also Ben, the idea surely is that Doctors have some “technical knowledge” in excess of the lay person, otherwise what’s the point of going into hospital in the first place?