As two junior doctors working in a small district general hospital with no escalation facilities for level 3 care, we regularly come across the need to establish our patients’ DNAR and escalation status soon after admission, as this directly influences their suitability for remaining as an inpatient at this site.
During the current Covid-19 pandemic, if a patient has tested positive or is awaiting a result and is for full escalation they must be transferred from our hospital to a different one altogether. This has prompted an increase in the number of DNA-CPR discussions we are having with our patients. In addition, in the current climate, we are frequently finding ourselves discussing suitability for ventilation. This is further prompting us to recognise that if a patient is not for ventilation, they are therefore not suitable for intubation in an arrest scenario, and a DNA-CPR form should be completed.
Resuscitation and ceiling of care decisions can be highly emotive and personal, resulting in complex discussions, and evidence shows that clinicians are often poor at communicating with patients about DNA-CPRs.1 This is often compounded by patients and relatives processing and adapting to a potentially life-changing diagnosis. There is never a ‘nice time’ for these discussions but it is often necessary to, when a patients’ circumstances change, or there is the potential for clinical deterioration, such as is the case in the current Covid-19 pandemic.2
Currently, the topic of resuscitation and access to maximal treatment is an area of concern for our elderly population. A joint statement from the Care Quality Commission (CQC), British Medical Association (BMA) and Royal College of Physicians (RCP) sets out the importance of advanced care planning and this explains the recent flurry of letters from GPs to their patients in light of the Covid-19 pandemic. 3
There has been public outcry at reports of GP practices writing to vulnerable patients suggesting they sign DNA-CPR forms with no face-to-face or even telephone discussion. 4 Here, there is a very real risk of patients and relatives feeling pressured into making decisions that could be detrimental to an existing patient-doctor relationship. 5
Effective communication is essential for shared-decision making
On our stroke rehab ward, we have had to consider establishing an escalation plan early, while approaching the topic sensitively and taking time to build rapport. This is particularly difficult when all communication is via the telephone so vital non-verbal communication and therefore empathy can be missed.6
The discussion can be even more challenging when patients or relatives do not agree with the clinical assessment that they would not benefit from escalating care to HDU or ICU. Fortunately, we have found that the majority agree and those who initially do not, often only require some further discussion and thinking time.
The emphasis of our approach is on building rapport early, by proactively contacting relatives and starting a friendly and open dialogue in which they are encouraged to ask questions and raise concerns. These are often centred around Covid-19 and while trying to ease these concerns it presents a good opportunity to raise the importance of having a plan in place should they deteriorate, regardless of cause.
Once this has been approached, we have found describing escalation and resuscitation as treatments, which may be appropriate or inappropriate to recommend for our patients useful. This may be helpful for patients and relatives to understand why we make our recommendations.
We emphasise that a DNAR does not necessarily affect any other aspect of care, not all treatments are withheld and we give examples of care and treatment we can deliver on the ward including oxygen, fluids and antibiotics.7 8
Effective communication can be the difference between shared-decision making and a patient feeling pressured and depersonalised, into a category of an elderly patient undeserving of escalation. The language we use can be very helpful in opening up the discussion and conveying that we have the patient’s best interests at heart. We have therefore included some strategies and phrases we have found useful in our clinical practice in the hope that other colleagues in similar situations might also find these helpful.
Strategies to help:
- Confirm that the relative is in a suitable place to talk and they have sufficient time for the discussion.
- Try to build a rapport with both the patient and family as soon as possible (ideally upon admission) as this builds a stronger foundation for DNAR and escalation discussions as all parties have established some level of trust.
- Discussions with a patient must happen prior to conversations with relatives, if the patient has capacity.9
- Explain broadly, the goal of resuscitation and that it is unlikely to be successful. It is important to discuss the impact it may have on their prognosis and quality of life should it be successful.9 10 11
- Continue to talk about treatments that are still useful and appropriate. These may include fluids, antibiotics, oxygen and other therapies.
- Avoid using phrases such as ‘futile’ and ‘slip or fade away.’ These are both emotive and open to interpretation.
- Open discussion about escalation and resuscitation can help to de-stigmatise the topic. This could be carried out in any healthcare setting regardless of a patient’s age or comorbidity.
Some useful phrases:
- We appreciate this may seem like it’s coming out of the blue, but it is important we have these conversations early so everyone is on the same page about what is best for (name), rather than communicating about this when it’s almost too late or when (name) is unable to talk to us about it.
- We feel that trying to re-start (name)’s heart if it was to stop naturally would be unlikely to be successful. If it was successful, given (name)’s (whatever reasons are appropriate e.g. their level of comorbidity) their health, quality of life and prognosis after the event could be significantly worse than it is now.
- Although we would not re-start the heart if it was to stop and would not ventilate with a tube if (name) was unable to breathe for themselves, there are lots of things we can offer (name) and we may be able to give treatments such as oxygen, fluids and antibiotics.
Dr Laura Kirkham and Dr Amy Fox, Trafford General Hospital
- Mockford C, Fritz Z, George R, Court R, Grove A, Clarke B, Field R, Perkins GD. Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation. Resuscitation. 2015 Mar 1;88:99-113.
- Fernando P, D’Costa DF. Discussing resuscitation with elderly patients. Geriatr Med. 2010;40(5):268-72.
- Care Quality Commission. Joint statement on advance care planning. [Internet]. CQC:2020. [Updated April 2020: Cited 2020 May 12]. Available from: https://www.cqc.org.uk/news/stories/joint-statement-advance-care-planning.
- The Guardian. 'Do not resuscitate' orders have caused panic in the UK. Here is the truth. [Internet]. Rachel Clarke:2020. [Cited 2020 May 12]. Available from: https://www.theguardian.com/commentisfree/2020/apr/08/do-not-resuscitate-orders-caused-panic-uk-truth.
- Geriatric Medicine. The age debate and access to Covid-19 care. [Internet]. Alison Bloomer:2020. [Cited 2020 May 12]. Available from: https://www.gmjournal.co.uk/why-all-covid-19-deaths-count.
- Mast MS. On the importance of nonverbal communication in the physician–patient interaction. Patient education and counseling. 2007 Aug 1;67(3):315-8.
- Resuscitation Council (UK). Decisions relating to Cardiopulmonary Resuscitation (3rd edition - 1st revision ). [Internet]. Resuscitation Council (UK):2017. [Cited 2020 May 12]. Available from: https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/.
- General Medical Council. Coronavirus: Your frequently asked questions. [Internet]. GMC: 2020. [Cited 2020 May 12]. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-hub/covid-19-questions-and-answers#End-of-life-care
- General Medical Council. Treatment and care towards the end of life: good practice in decision making. [Internet]. GMC: 2010 [Cited 2020 May 12]. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life.
- Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in survival after in-hospital cardiac arrest. New England Journal of Medicine. 2012 Nov 15;367(20):1912-20.
- Meaney PA, Nadkarni VM, Kern KB, Indik JH, Halperin HR, Berg RA. Rhythms and outcomes of adult in-hospital cardiac arrest. Critical care medicine. 2010 Jan 1;38(1):101-8.