Critical Care with Covid-19: If the worst should happen…
I’d like to talk about Do Not Attempt Resuscitation (DNAR) Orders. It’s a delicate subject and, believe it or not, I’ve not always been famed for my tact, so I’m a bit scared to approach this one. But I figure if it’s not the easiest topic for me to talk about, it must be a lot worse for people who’ve never contemplated the subject before. I am aware that I see a lot more death than most, particularly in the last year. It’s unusual for most people to see a dead person these days, for me it’s probably well into double digits. I do also tend to see the world very black and white, that’s just the way I am. Sometimes I sound harsh or uncompromising. I’m trying to approach this with sensitivity, but sometimes the reality is pretty stark and my reality is a little different to a lot of people’s. I’m going to say dead a lot of times. I’m not aiming to shock. Death is a part of life and I think the words we use matter. I don’t like passed, like a bus going by, or lost, like someone was careless. I think it’s important to use the words dead and died. It’s a part of life and the more we talk about it, the easier it is to manage how we feel about it. If that bothers you, this may not be the article for you.
Do Not Attempt Cardiopulmonary Resuscitation. DNACPR or DNAR or DNR. Pretty much does what it says on the tin. Do not attempt CPR in the event that this person’s heart should stop. The first point that I’d really like to make clear, is that you have to have already died for this piece of paper to take effect. What it does not mean, is stop treatment before that has happened. It doesn’t mean stop treating someone, it doesn’t mean stop caring for someone. Dead or alive; we don’t stop caring for you until you physically leave the unit. We will not stop doing the best we can for you.
The DNR only takes effect if your heart has stopped beating in a rhythm that produces a pulse. I’m saying it again: At this point you are dead. Usually this decision has been made because the medical team caring for a person does not believe it is likely to succeed. CPR is not dignified. It’s brutal. You have to squash a person’s chest by about a third to give good quality compressions. That breaks bones, particularly in the elderly. And if you feel their ribs break (and believe me, you feel them) you keep going. You continue to press, hard, repeatedly, on broken bones. It is worth it if they live. It amounts to a very sore chest when you wake up. But if you were never going to survive, it is messy and undignified.
The survival rates for cardiac arrests (heart has gone into a rhythm that does not produce a pulse = dead) are very poor. Out of hospital, in the UK, it’s slightly less than 1 in 10. In hospital it’s about 1 in 5 (quick access to skilled personnel and early defibrillation). On TV medical dramas it’s really misrepresented, arrest in front of people and 9 times out of 10 they’ll get you back. I think it gives people really unrealistic expectations of what can be achieved. It does depend on what has caused you to arrest, but the odds are just not that good. Because something has caused you to die.
There’s also the question of what are we bringing you back to? About 15% of the people who survive will have lasting cognitive impairment impacting upon their day to day living. That’s brain damage to me and you. That could be slight, some loss of dexterity or understanding or speech. Or it could be huge: not able to perform any basic activities for yourself. It could mean a nursing home for the rest of your days. It might be another week in an ITU before you die. The question of what is an acceptable quality of life to you is really very personal. As is what are you prepared to go through to live? ITU is hard, as is the rehab afterwards. Some people would be happy with the nursing home, as long as they know what’s going on. To some people being in a nursing home unable to care for yourself is unacceptable.
I read something on the news last week about families not being consulted prior to DNRs being put in place. This is really hard. It does happen occasionally. Sometimes a person deteriorates very quickly, and a decision needs to be made right now. We would always aim to discuss it with the family as soon as is possible. But sometimes a decision has to be made. This is the part I’m nervous about explaining. The decision to put in a DNR is a medical decision. We would always try to discuss it with the person it affects, firstly, and their family. We desperately try not to put one in place without the family’s understanding and consent. But at the end of the day it is a medical decision. This is because it is simply not fair to place that burden on someone’s family. They are emotional, too close to the situation and frankly (for the average joe), cannot possibly understand the full medical situation. Please don’t get me wrong, we will explain as much as is humanly possible, we will support and lay out options and explain what we intend to do. But this medical decision is made by a team of highly trained people who have years of experience informing their decision.
I’m hoping this helps you to understand the realities of these decisions. They’re not put in place arbitrarily. It’s not a decision we take lightly. We do agonise at times. It’s right that we do. The best advice I can give you is to have the conversation now. Not when you’re sick, or going into hospital and would rather not deal with your own mortality. It’s easier to discuss when it isn’t crucial a decision is made. What would you prefer? Would you want to be resuscitated? Would you want intensive care? Would you like to donate your organs if it came to that? They’re never the easiest conversations. But talking about it now is a lot easier than a doctor sitting you down and asking you ‘Do you know what they wanted?’ and you not having an answer.