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Health

'Do not resuscitate' orders have caused panic in the UK. Here is the truth | Rachel Clarke


The outrage over allegations that doctors have apparently been using the coronavirus pandemic to write off whole swathes of vulnerable patients has been painful to witness. According to news reports, we have been condemning elderly patients to a “do not attempt cardiopulmonary resuscitation” order – a DNACPR – without so much as a discussion. The anger centred on care homes in East Sussex and Wales whose elderly residents were categorised en masse as not being appropriate for resuscitation.

No wonder people are distressed. The latest data from the Office for National Statistics, which provides a demographic breakdown for 647 deaths from coronavirus registered before 27 March, shows that more than two-thirds (69%) occurred among those aged 75 and over. So it is understandable that public feelings are running high: hostility is invariably unleashed by fear – and in these locked-down, revved-up times, fear is as contagious as coronavirus itself.

Even at the best of times, the notion of anyone – doctors included – holding your life in their hands is deeply uncomfortable. Rumours from other countries hit hard by coronavirus have only heightened anxieties. In Lombardy in northern Italy, for example, some hospitals have allegedly been forced to impose rationing of care on the basis of age – with only those aged 65 and under being eligible for a ventilator.

As tempers fray, sifting facts from hysteria may provide welcome reassurance. Cardiopulmonary resuscitation – CPR – means something very specific. It is the term we use for chest compressions and electric shocks to a heart that has stopped beating. It is treatment that is exclusively for someone who has already suffered a cardiac arrest. In a sense, the patient has already died: we are trying our hardest to resurrect them.

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Some people fear a DNACPR order means nothing at all will be done to try and prolong a patient’s life. This is not true. All manner of other treatments may be appropriate, such as fluids, antibiotics, oxygen, admission to hospital or treatment in an intensive care unit. The only thing ruled out by a DNACPR is chest compressions and shocks to the heart.

When a patient is “for” CPR – if their heart stops – a call is put out to the hospital crash team. The team arrives and sets about the chest compressions, the shocks and, in all likelihood, intubation – a tube inserted down the throat into the lungs in order to deliver oxygen. CPR is muscular, aggressive, traumatic. When I was taught how to do it, the instructor said: “If you’re not breaking ribs with your compressions then you’re just not doing them properly.”

Sometimes – though rarely – all this effort reaps rewards. When we bring a patient back from the dead, we want to shout from the rooftops. But too often, the rigmarole is futile. The heart cannot be restarted because the patient is too frail, too weak and waning. Their cardiac arrest has not been caused by a reversible problem. Rather, it is the natural end of their life – the heart has stopped because the patient is dying. In these cases, all we have achieved is an ugly, brutal cacophony of noise in place of dignified dying.

In the UK, unlike in north America, the decision whether or not to write a DNACPR order rests with the clinician, not with the patient or their family. Doctors, not patients, sign the order – contrary to some of the rumours on social media.

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Any patient with capacity can decide from themselves to refuse CPR and request that a doctor completes a DNACPR form on their behalf. But no one can insist upon receiving CPR. Like all other medical treatments, CPR will only be administered if a doctor believes it is in the best interests of the patient. And in all cases patients never complete the forms themselves, doctors do.

In the 11 years I have been a doctor, not once do I recall my colleagues taking these decisions lightly. We initiate DNACPR discussions with patients when we fear CPR would be futile. We do so as an act of respect and kindness. We are trying to put you, our patients, first. I have held this conversation hundreds of times – always endeavouring to act in your best interests.

Ideally, the patient should be at the heart of these discussions. Failing that, then their family, loved ones or advocate should, if possible, be consulted. But pandemic medicine, we are learning, is far from ideal. Frontline staff are rushed, overwhelmed, working to their limits. It is clear that some DNACPR “discussions” have been compressed into impersonal emails or letters or – even worse – not happened at all. These failures of communication have rightly been called out as unacceptable.

But please know that if your doctor seeks to broach DNACPR with you, we are doing so not to “ration” care but rather to ensure you are not unknowingly subjected to a futile and inappropriate treatment. We are not giving up on you. At the time of writing, the UK has several thousand spare ITU beds. No one is being denied either an ITU bed or CPR on spurious grounds. Pandemic or no pandemic, we are trying our very best for you.

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Rachel Clarke is a palliative care doctor



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