Musings Part 12: How much of this description of a DNAR is correct ?

Posted in: Older people's nursing | Specialist nursing areas

22-Jun-2011 9:48 am

Posts: 105

This was a ‘general comment’ from a late draft of a recent CPR/VoD Policy:

The following general points however should be noted. A DNAR Order:
a) Does not routinely have expiry date unless a specific date is recorded
b) Can be in many forms (verbal, letter, form)
c) Is an expert medical opinion as to the effectiveness of resuscitative efforts
d) Can be used across acute (hospital), primary care and community based services
e) Is valid across boundaries both county and valid for all of the UK
f) Should be filed in the front of the patient’s clinical records (where possible)

How many of those statements, are unambiguously true ? Or unambiguously false ? And, which ones ?

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DH Agent - as if !

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30-Jun-2011 12:25 pm

As this one does not affect the others, and the answers are actually pretty obvious, and I'm bored, I will put them (mine, being picky) up now.

If we take the word 'general' to mean 'always/invariably' then we have:

a) it can't have an expiry date, and be complaint with the MCA, even if one is present on it - the MCA, clearly expects a person who is making a best interests decision, to act on everything he is personally aware of at the time the decision is made. Contemporay DNAR orders, are a predicted best interests decision, and should be reviewed as soon as something relevant changes, not just at fixed dates !

b) this is confusing to the point of being nonsense. A DNACPR decision exists inside someone's head, and knowledge of the existence of that particular decision, could be communicated in numerous different ways. But, it would be better in a CPR/VoD policy to use DNAR Order for the things doctors currently sign, and to use DNACPR Decision, for everything else, and also more generally. Otherwise, it can get very confusing !

c) no it isn't, because a patient can refuse CPR while it could still work, and while CPR could still work, the patient's instruction is what justifies a DNAR Order ! It is only a purely medical opinion, when it has been decided in advance that future CPR attempts would fail - in which case, the DNAR Order seems to be pretty pointless !

d) This is an objective, but using the word 'can' is probably wrong: the difficulty, is that the reader of a DNAR Order, is in theory obliged to use the DNAR Order as 'guidance' and not to merely follow it.

e) Definitely wrong, as in England CPR is legally governed by the MCA, and the MCA is not the law in Scotland (oddly, Scotland's CPR Policy is almost 'correct' if one starts from the MCA !)

f) That one makes sense !

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Anonymous

30-Jun-2011 1:37 pm

an explanation of all the abbreviations might be a good start!

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DH Agent - as if !

Posts: 105

30-Jun-2011 3:14 pm

30-Jun-2011 1:37 pm

DNAR = DNACPR and both stand for 'Do not attempt (cardio-pulmonary) resuscitation.

CPR = cardiopulmonary resuscitation

CPA = cardiopulmonary arrest

All of the above, neglecting the possible complication of someone having a beating heart but not being breathing, just mean we are considering the situation of a patient who has stopped breathing, and whose heart has stopped circulating any blood.

MCA = Mental Capacity Act 2005 (amended 2007) which defines the law for the treatment of anyone who is mentally incapable, and cannot refuse an offered treatment because of that incapacity: it does not matter how temporary such mental incapacity is, and patients in CPA are always mentally incapable within seconds because of the lack of oxygen reaching the brain.

Sometimes, DNR was also used for DNAR/DNACPR (there seems to be a move towards settling on DNACPR, but as usual people will insist on using different labels, for the same things - and sometimes the same word, for different things, which is actively bad !).

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Anonymous

30-Jun-2011 3:41 pm

thank you. hopefully this will make your posts easier to understand.

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Anonymous

30-Jun-2011 8:09 pm

CPR/VoD policy

please, what is this? I tried to find it on Google to avoid asking again but all it comes up with is all your posts in NT!

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DH Agent - as if !

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1-Jul-2011 11:13 am

Anonymous

Anonymous

30-Jun-2011 8:09 pm

An interesting question !

These are the Policies currently written by groups of people (nurses, hospices, police, etc) who are invariably 'overseen' by the local Coroner, and assembled by either a Primary Care Trust or a Strategic Health Authority. Often, the Policy will have a title such as 'Policy for the Management of Expected Death in the Community'.
Essentially, the policy will try to address the complication that only a GP can certify a death, but some deaths are inevitable and anticipated to the point when a local Coroner will formally allow suitably trained non-GPs (usually trained District Nurses) to verify the death, and arrange for the removal of the body, without having to involve anybody else in the process. Effectively, the nurses are allowed to carry out the post-mortem formalities if the GP cannot attend, because the GP has 'promised in advance, to certify the death'. This is supposed to speed things up, and make things better for the bereaved.
The problem, is that these policies tend to confuse the 'rules' for CPR decision making (ie 'am I supposed to try to resuscitate this patient, or am I supposed to let him continue to die in peace ?) with the problems of verification and certification (something entirely different). It is not 'CPR & VoD' but rather 'CPR then VoD'.
Curiously, how ill, or near to death, the patient is before his heart stops, is only relevant to the VoD (the entirely post-mortem ) part of the problem - the relevant consideration for 'should I try to resuscitate him' is 'would he consider his clinical situation, and wider life situation, after the proposed resuscitation attempt, acceptable {if I could somehow ask him while he is unconscious} ?'.
I do not like the current 'belief and behaviour set' in this area, as it is offensive to patients and their relatives, departs from logic, in my view departs from the law, and has far too much 'back-covering for professionals' written into it. It is, quite complicated ! And the debate, gets very detailed, and very lengthy.

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DH Agent - as if !

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1-Jul-2011 11:15 am

CPR/VoD policy

Try looking for 'expected death' and 'sudden death' on Google, instead of CPR/VoD.

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DH Agent - as if !

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3-Jul-2011 12:44 pm

30-Jun-2011 8:09 pm

I originally worked out why expected death exists – its purpose – within a few minutes by reading the (partial) policy you will find at:

http://www.devonlmc.org/Articles/Confirming%20Death.pdf

The crucial clues are: ‘Following meetings between the Chief Officer of Devon LMCs and Mr Richard Van Oppen, HM Coroner for the County of Devon’ and also this statement: ‘The working party hope that all health professionals and others engaged in the care of patients either alive or dead will use these guidelines in that spirit.’

We are not told what the Coroner and the chairman of the working party discussed, before the chairman’s group then created the policy, and the ‘spirit’ is not spelt out in detail. But if you read and analyse that document, it becomes quite clear WHY Coroners ALLOW ‘expected death in the community’ to exist – with a little more thought, it is easy to see that current behaviour totally ignores that really there are 3, not 2, ‘types of death’.

The actual law, and other specifics, have changed a bit since that document was written - but, the reason why expected death exists as a 'concept and behaviour guide' remains unchanged.

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Anonymous

3-Jul-2011 3:48 pm

Sorry i phrased my question badly. I was just wanted to know what the abbreviations stand for without the need for lengthy explanations as these are not universally used. It is all clear now and I presume VoD means verification of death.

we try to discourage using abbreviations in medical and nursing practice as they are sometimes ambiguous, cause confusion and if used in instructions for patient care have in a few instances proved to be very dangerous.

Also it slows the reading process of comments if the reader works in a different area of practice and is unfamiliar with these.

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DH Agent - as if !

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16-Jul-2011 1:59 pm

3-Jul-2011 3:48 pm

The problem is worse than abbreviations - there is not, currently, any natioal-definition of the term 'expected death'.
Protocols do use DNAr or DNACPR, but without being clear exactly what they mean - I have seen at least one comment, when an author of apolciy was using DNR (which used to be quite common' that the local distric tnurses wanted something else, as 'we use DNR for 'district nurses request' !

Just for my own clarity - are you saying the abbreviations are not universally used, or my own definitions are not universally used ? I know my own preferred definitions, are not currently used - especially for 'expected death': but my definitions are consistent with the law and logic, which is more than I can say for a lot of published material in this area !

Sorry if my typing is really awful today - forgot my reading gasses and can't see the screen very well !

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