Adhering to DNAR orders…

Patient wishes should be at the heart of their care and inform treatment decisions.  Where a patient is mentally competent and able to make decisions about their end-of-life care, either at the time or in advance of a loss of capacity via an Advance Decision to refuse treatment (or a DNAR), this must be respected.  The coordination of such information is also called into question by the study.

This report shows that 52 patients were let down because their explicit decision to refuse resuscitation was ignored.  There is still a medical culture of over-treating patients and prolonging life at all costs as highlighted by this study, although this is starting to change. As well as the recording of patients’ wishes, it is of vital important that these can be accessed by the patient’s healthcare team.

Having conversations with end-of-life patients (or their loved ones if the patient has lost capacity and has no recorded wishes) about what sort of medical interventions they would or wouldn’t want to keep them alive can be difficult. However, these conversations are important so that the consequences of accepting (or not) life-prolonging treatments are fully understood. For example, will the patient have a quality of life that is acceptable to them and what are their chances of recovery?
These discussions must go beyond DNAR and also include other medical interventions which may prolong life such as artificial nutrition and hydration and antibiotic use.  These conversations, and the formal documentation and sharing of decisions, should ensure that patients can have what they consider to be a good death.

In conclusion, more work needs to be done to ensure that patients know they have the right to refuse treatment, either at the time treatment is suggested or in advance using an Advance Decision or DNAR form. Healthcare professionals need training and support so they are confident to discuss these difficult decisions with patients, and systems must be in place so that they are aware of these decisions. Importantly, they must respect patient’s decisions, regardless of their own views of what treatment they would want in that situation.