Do Not Resuscitate (DNR) orders

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elacsaplau

Registered User
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Just a few questions about DNR orders.

Specific

1. Where someone has lost capacity, who decides?
2. Do most nursing homes have a default position?
3. What is the legal role of next of kin?

General

1. Is there decent guidance notes available on the issue?
2. When do you think it is ethically justifiable to put a DNR order in place for someone who has lost capacity?
 
elacsaplau said:
1. Where someone has lost capacity, who decides?
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The next of kin. Afaik
elacsaplau said:
2. Do most nursing homes have a default position?
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Most nursing homes would be very anxious that they not be responsible for any decision not to resuscitate, they will err on the side of resuscitating if in doubt.

elacsaplau said:
3. What is the legal role of next of kin?
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The legal position is that the patients welfare is paramount. Where someone has lost capacity, that effectively means the next of kin, with medical advice having a sort of veto.


elacsaplau said:
1. Is there decent guidance notes available on the issue?
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Don't know.

elacsaplau said:
2. When do you think it is ethically justifiable to put a DNR order in place for someone who has lost capacity?
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In my opinion the feelings of the next of kin should be the important thing here. Nothing worse that thinking for years after that "we could have done more" or alternatively "we prolonged their suffering". Not easy for all the next of kin to be in the same place. And every persons situation is different.
 
I think the Ethics should probably touch on "Is a meaningful recovery or quality of life possible?", "Did the patient give any indications before they lost capacity?".

You could research "Enduring Power of Attorney", probably more for the knocked down by a bus, rather than end of life scenario. But I think there's something like "Living Will/Advance Medical Instruction" when you can spell out what, or what not you want to happen. I've done the enduring power of attorney - basically allows herself to making decisions for me. Don't think it included Advance Medical, but I often joke that if I go gaga just pop me on a plane to Switzerland and I'll come back by DHL.
 
Thanks Cremeegg,

I thought it (DNR) was ultimately a decision taken by medics and that the family's wishes are taken into account by the medics. I am not sure to what degree the medics follow the family's wishes or what happens when the family is not in accord on the issue. Hopefully, someone will clarify/explain the legal and practical applications.

One specific question in this context, is "next of kin" singular (as in the spouse of the individual) or is it all his immediate family (i.e. spouse and children)?


Thanks Young Betsy,

I'd prefer to stick with the DNR piece for now rather than branch out into EPOAs and all that stuff.

The ethics question is interesting. What do we mean by a meaningful recovery or quality of life? For example, say someone had a stroke and was wheelchair bound and had diminished cognitive capacity also as a result of the stroke. Would a DNR have been put in place for that person pre-stroke? Should a DNR be put in place now? Crucially, if a DNR should now be put in place, why is this appropriate? If it's because the quality of life is not deemed sufficiently good to "fight" for, what does that mean - what are we really saying?!
 
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I suppose most people would agree "vegetative state", if that is a real medical term, is not meaningful life and if there isn't a chance to come out of it then what's the point. I refer you to the case of One, by Metallica;

"Fed through the tube that sticks in me
Just like a wartime novelty
Tied to machines that make me be
Cut this life off from me"

The real horror there being person had full cognitive ability but no expression. Fairly depressing film I'd say, the long video had clips from it.

While I'm sure this is ageist and makes me a bad person, wouldn't age come into play? If someone is in their 90s maybe you don't keep putting them out on the battlefield???
 
Thanks Betsy Og,

I've been thinking aout this.

It seems in Ireland that to do:
(a) nothing (DNR) to purposely end suffering/poor quality of life is generally deemed acceptable.
(b) something to purposely end suffering/poor quality of life is generally not deemed acceptable.

Is this accurate? Does it make sense especially if the "suffering" in (b) is much greater than the suffering in (a)?
 
I say that about covers it.

I wish that citizens assembly had been give a go at this & we get a referendum (not how young should the Pres be :rolleyes:). I'd consider abortion to be a lot more controversial than this topic, so I think we shouldn't be afraid to explore it. Subject to a rake of medical criteria I think people have a right to call time - I'm not pro-suicide, very much the opposite, but I don't see why the terminally ill are forced to suffer and wither into death - how often have we heard the phrase "you wouldn't do it a dog".
 
Seems like we're having a private chat, Betsy Og!

I'd like to pose/repose some of the specific questions.

1. Who decides to activate a DNR in practice?

2. Does the DNR typically just cover CPR? (……..as in could a defibrillator still be used......the thinking being that CPR may be too violent/cause internal damage on an old person)

3. Is the next of kin the spouse and does the spouse's opinion matter most in determining the family's wishes?
 
Recently had this with an uncle of mine who was down syndrome and living in residential care. When he got sick and was in hospital, a DNR was put on his chart. None of the family were consulted and the residential house said that they would not give the instruction without consulting the family.

As far as I know there is no legislation in this area. I don't even think there are guidelines. It is down to the doctor but I think it is accepted that they should always consult with the family but I don't think the doctor is obliged to accept the family wishes.
 
This is a difficult situation, especially for the nearest and dearest.

My own experience of three of my relatives, two in Ireland and one abroad, was that clinicians were very sensitive and gave us copious medical information and as much time as we needed to reflect.

From their medical history, one with motor neurons and two with previous resuscitations, we knew that there was no hope, but it was really hard to let go.

We went through all the what ifs,- internet searches, possible clinical trials, possible alternative treatments, possible breakthrough treatments, all of which came to nothing.

In the end we had to decide which was more important; our need or their suffering.

We made the heart-rending decision to let go.

It was the right decision, but it took an age to understand the false associated guilt.

We eventually accepted that there was just nothing we could do.


AFAIK, clinicians make the DNR decisions.

In my experience they consult the family, spouses first, children next, siblings next, etc.
 
Excellent post Sophrosyne


To my mind the process you outline

Sophrosyne said:
we knew that there was no hope, but it was really hard to let go.

We went through all the what ifs,- internet searches, possible clinical trials, possible alternative treatments, possible breakthrough treatments, all of which came to nothing.

In the end we had to decide which was more important; our need or their suffering.
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is very important. Until things have reached this stage and the family can see things in this light, you cannot justify a DNR
 
Sunny said:
None of the family were consulted and the residential house said that they would not give the instruction without consulting the family.
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Either the "family" don't remember or the residential house have made a mistake. My sense is that the family is unlikely to forget so it's an extraordinary oversight by the residential home.

Sophrosyne said:
.....we knew that there was no hope
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Thanks Sophrosyne,

I don't mean to be insensitive but I'd really like to understand the quoted bit more......what exactly does "no hope" mean here?

Is it that the person concerned would have a very poor quality of life if successfully resuscitated or is it that the person is expected to die shortly thereafter anyway (and if so, does shortly mean weeks or months?) or do you mean something else?
 
elacsaplau said:
I don't mean to be insensitive but I'd really like to understand the quoted bit more......what exactly does "no hope" mean here?

Is it that the person concerned would have a very poor quality of life if successfully resuscitated or is it that the person is expected to die shortly thereafter anyway (and if so, does shortly mean weeks or months?) or do you mean something else?
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There was no hope of survival beyond a few hours.

They were all in great pain, and in one case in agony.
 
elacsaplau said:
It seems in Ireland that to do:
(a) nothing (DNR) to purposely end suffering/poor quality of life is generally deemed acceptable.
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Had a family member recently pass away.

I'm not sure the point above is accurate.

End of life care (via a palliative care team) was administered. ie. Morphine and Propofol
 
HollowKnight said:
Had a family member recently pass away.

I'm not sure the point above is accurate.

End of life care (via a palliative care team) was administered. ie. Morphine and Propofol
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Yep, that's my experience as well; Morphine them into oblivion.
 
Thanks HollowKnight and Purple,

Can you elaborate on the difference between "morphine to oblivion" versus "euthanasia" please?
 
I can only speak from my own experience.

Family member was non communicative during the last week of life. Lying in hospital bed and occasionally showed signs of agitation - the doctors expressed that they thought this was sign of pain/discomfort. They decided that more painkillers and sedatives would be helpful (to family members more than the patient?).
 
Thanks HollowKnight,

Firstly, I am sorry for recent loss. Also, if my question to follow is insensitive, I apologise.

Are we saying that painkillers (at the end of life stage) have the dual effect of easing the pain and shortening life? Is this correct and if so does it not follow that there's a soft border between palliative pain relief and euthanasia?

[Sorry Purple just saw your post after drafting this!]
 
I’m not sure where you are coming from on DNR orders @ elacsaplau.

This is not a black and white issue and I don’t think it should be expressed as such.

In my experience, the DNRs were the last resort after long and painful illnesses and as I mentioned in the case of two relatives, there were several previous resuscitations.

The success of resuscitations depend on a patient’s condition. Sometimes their bodies just can’t take it because besides the heart, other vital organs are diseased and have already began to shut down.

Resuscitations are invasive and traumatic for the patient and carry risks.

If the medical advice is that a resuscitation is unlikely to be successful, relatives have to decide whether it is better to put their loved ones through the trauma of a pointless attempt at resuscitation during which they may die anyway in distressing circumstances, or let them spend their last few days/hours in peace with palliative care and surrounded by their family, friends, etc.
 
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