Better communication needed for DNRs and end of life care planning
Do Not Resuscitate (DNR) orders are designed to ensure a peaceful and dignified death for those that would not benefit from resuscitation, whether that’s because of their existing medical condition or the risk of further treatment if the CPR were to be successful. There are few who disagree with the principle of ensuring a patient can die with dignity, however the critical issue is how a DNR is created and communicated.
It’s no secret that DNRs have been a high profile subject for the media. Since the retirement of the Liverpool Care Pathway, DNRs have featured in much of the commentary around end of life care. One doctor’s perspective suggests that we need to put kindness back at the centre of end of life care, while another suggests that asking patients to sign a form acknowledging their terminal status is ‘cruel’. So, is the issue one of kindness?
The thought that one in five families have no awareness that a DNR order is in place on their loved one is terrifying and certainly doesn’t sound like kindness. It’s been labelled as ‘unforgivable’ that families are not always given the opportunity to fully understand and discuss the decision with a senior healthcare professional.
However, it’s not necessarily a matter of poor practice, just poor communication. A landmark case made it law for patients to be consulted about DNR decisions (if they have capacity) and notes kept on the discussions held with families, so is better record-keeping needed?
In a recent #NurChat discussion, nurses and healthcare professionals re-iterated the important role that families have in a person’s end of life decisions. Leaving the discussion until it’s too late deprives the individual of the chance to be a part of the decision-making process. In some areas of the country, Treatment Escalation Plans (TEP) are replacing DNR forms in a bid to more effectively manage end of life treatment. They allow a more in-depth and legally-binding record to be kept of the level of treatment that’s appropriate for a patient, rather than just their DNR decision. Crucially, TEP forms also feature a section to record the discussions held with families and relatives.
Communication with families not only helps them to understand their loved ones wishes, it also gives them reassurance that the medical and nursing staff are doing everything that’s necessary in terms of treatment or interventions. As a society we can still view death as a taboo subject, but shying away from the conversation isn’t helping. As a community of nurses and healthcare professionals, we need to be confident that we can find the right time to make sure a patient is involved in their end of life planning.
NurChat returns on 7th June 2016 at 8pm when we'll be talking about respect for carers - do we value their role?