End of Life Discussion

Question 1

Reasons for DNAR form

Answer 1

Resuscitation is unlikely to be successful
Patient does not want it
May be successful but will result in a quality of life that is unacceptable to the patient

Question 2

Who should be informed of DNAR decision?

Answer 2

Patient should be informed if they have capacity unless it will cause significant physical or psychological harm

Relatives of patient should be informed if patient lacks capacity

Question 3

Important points

Answer 3

Medical team decision - patient can refuse resuscitation but not demand it
Success is around 20% in-hospital adn much lower if comorbidities/other reasons
DNAR discussions should be clearly documented
DNR does not mean stop treatment
Form should be countersigned by consultant ASAP

Question 4

Structure

Answer 4

Start by talking about current problems and treatments being given

Explain risk things may get worse and patient may deteriorate

Explain resuscitation and what it involves

If CPR would not be successful, explain why the team feel it would not be appropriate.

If CPR may be successful, discuss their wishes and feeling and try to determine whether the benefits would be greater than the risks and burdens and if level of recovery would be acceptable to patient

Stress that it does not mean patient will not be treated - form only matters if heart stops

Don’t force it - escalate to seniors

Question 5

Phrases

Answer 5

One thing that is important to talk about is resuscitation

You are very unwell at the moment and we need to talk about what we would do if you were to get worse despite treatment

We feel it would be kinder and more appropraite to ensure he/you are not in any pain or distress in the last moments of life.

If it were to get to the point where his heart were to stop, we would not try to restart it

We will still give every treatment available on the ward, the form just means that if she were to become much more unwell and reach the natural end of her life, we would not do chest compressions and shocks to restart the heart - this can cause a lot of pain, distress and prolong suffering

Eventually, his medical condition will mean that at some point he will get to the natural end of his life and it is important we talk about this before it happens

Trying to restart the heart in this situation would not be the right thing to do

We only have one change at end of life care so we want to get it right

Even if a patient survives resuscitation, they are more disabled after and left with a quality of life they would not want

Question 6

Risks of CPR

Answer 6

Rib fracture
Damage to internal organs
Adverse clinical outcomes - hypoxic brain damage
Increased physical disability
If CPR is unsuccessful - dying in undignified and traumatic manner
Long term illness still present

Question 7

Treatment escalation plan

Answer 7

Decisions regarding other invasive treatments

Patient can only insist on things that they do not want

It is for doctors to decide which treatments are appropriate and should be offered and which treatments are not appropriate
e.g. ICU, NIV, parenteral nutrition

Question 8

Approach to discussion

Answer 8

Setting
Perception
Invitation
Knowledge
Emotions/Empathy
Strategy/Summary

Explain to family you will involve palliative care team and offer religious input where available

Ensure you talk about patients symptoms and reassure they can be managed

Has entered the final stages of his life
Further invasive treatment and tests will not make a difference and prolong suffering
The most important thing now is to make sure he is comfortable and not in any pain or distress

Question 9

Consent for post-mortem

Answer 9

Coroner’s post mortem - relatives cannot decline
Consented post-mortem - for educational purposes - written consent from next of kin

Incisions hidden by clothes/hair
All tissue replaced unless required by coroner
Takes around 3h
Done within 2-3 days so funerals not delayed
Report sent to coroner/consultant and GP

Question 10

Brainstem death

Answer 10

Irreversible loss of all brain and brainstem function
Confirmed by two qualified specialists who do a series of tests independently looking at brainstem reflexes and breathing

Explain that we should now turn off the ventilator

Question 11

Organ donation

Answer 11

Explain what it involves
Explain benefits
Reassure about funerals and fairness of organ allocation

Donation may occur after brainstem death, circulatory death, living donor
Cannot donate if HIV, mets, CJD
Consent can be from pt or relative
If pt consented before death, relatives cannot override