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CNO to review form after concerns raised over DNR question

The chief nursing officer is to review the way community nurses discuss end of life care with older patients, particularly wishes concerning resuscitation, following criticisms in the national media.

Writing in her latest blog, CNO for England Jane Cummings said she was disappointed at reports claiming dialogue with patients over their wishes concerning resuscitation was handled in a blunt and impersonal way.

“We will review the form again, with patients and clinical staff, in the light of the poor experiences described in the media”

Jane Cummings

It follows claims that patients were being asked whether they would agree to a “do not resuscitate” order by district nurses they have not met before, under an NHS England questionnaire scheme.

Health policy analyst Roy Lilley told the Daily Mail he had been contacted by relatives of elderly patients with concerns about the form, including two that were asked over the phone. He claimed the question was inappropriate, especially if asked by someone who had not previously met the patient.

Roy Lilley

Roy Lilley

Ms Cummings said she had spoken with Mr Lilley, who described the experience his mother had, which she noted was “upsetting and should not have happened”.

“As a nurse, I was very disappointed to hear that story,” she said, adding that most nursing staff “would never dream” of asking patients where and how they would like to die in an “insensitive or bureaucratic way”.

“It needs to be part of an ongoing discussion that develops out of a meaningful relationship between a nurse and patient and their families,” she said. “The aim is not simply to work through a document and tick it off, but to ensure that every patient’s questions, concerns and options have been addressed.”

Ms Cummings said the document in question – Avoiding unplanned admissions enhanced service: Proactive case finding and care review for vulnerable people – was intended to help clinicians develop personalised care plans with vulnerable patients who had complex healthcare needs.

The form includes questions on allergies, medication and people’s emergency contacts. One question relates to emergency care and mentions resuscitation as a possible discussion point.

Jane Cummings, Chief Nursing Officer for EnglandJane Cummings


“Clearly if this conversation is appropriate for the patient, and as the form suggests it might not be, then it should be handled with great care,” she said Ms Cummings.

“We will review the form again, with patients and clinical staff, in the light of the poor experiences described in the media and make any changes that are needed,” she said.

“Compassionate care should be at the heart of all conversations and relationships between a nurse and patient. Poor implementation of a document by individuals is no excuse for causing distress to our most vulnerable patients and their families,” she added.

Readers' comments (17)

  • Once something is documented on a form it becomes tick box and measured. Unfortunately not all nurses will recognise that the discussion may be inappropriate or lacking in compassion. There is also the question of time - do these nurses have the time to develop a relationship with the patient or is this seen as yet another chore to complete with limited resources?

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  • If lack of time and adequate staffing level are the main factors affecting compassionate nursing care, then it become apparent that Nursing is at stake.

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  • Cant help thinking this is designed to prevent patients being admitted to hospital if their condition may lead to cardiac arrest and so DNR will mean, "Do not admit" because the right tick boxes say so

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  • We had a 30-stone patient who opted for resus., should such a need have arisen. Nurses were scrambling about finding a stool high enough to reach the man's chest. His stomach was extended so far above his chest that massaging his heart would have been impracticable.

    DNR should have been the only opted for this patient, and we should not have been left trying to work out how we would reach him (his bed and body were so high that we could barely reach the top of him. In order to attempt resus, we would likely have to climb onto the bed). [The reason DNR ought to have been the only option is due to many other health conditions and complications linked to obesity, rather than just the impracticality of resus for him, though this is an important issue.]

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  • As a staff nurse on a rehab ward, where the majority of our patients have complex health needs, my experience is that the majority would have benefited from a discussion in their own homes about their future care wishes. I really, really hope that this bad press will not halt this sensible and caring move to give our patients the choices they deserve. For every one complaint, I feel certain there will be hundreds who feel relieved that as nurses we've had the courage to raise the issue.

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  • michael stone

    The whole area of 'talking about dying' and the associated 'planning for death' is fraught, confused and not joined up - it needs a lot of work (as, even more so, does thrashing out the law around dying, and post-mortem behaviour for home EoL deaths).

    and several others on the BMJ, intended to promote 'more thinking' about these issues.

    For example, section 3 of the Mental Capacity Act, does not describe how mental capacity is assessed:

    And 'shared decision-making' is a truly strange term:

    But just for once, the Mail might have got this one right: while patients need to express wishes about CPR early enough for their to be a point to that, nobody should 'suddenly drop the question on them' without a very good reason to do that. Although sorting that one out, seems to me to be one of the simpler EoL issues to address: if it has been happening, I suppose it is the result of some absurd bit of 'box ticking' coming from somewhere [in 'the system'].

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  • I agree that any nurse who has to ask a patient she hardly know about end of life decisions could completely undermine any trust the patient may have in her/him. How intimidating to go into an elderly persons home and ask 'Do you agree to not being resuscitated'? I know the elderly are seen as flotsam by many people nowadays but this is just cruel. Once the nurse has built up a rapport she should explain it is a question she has to ask to all patients she sees while they are moderately well, and then ask, 'if you collapsed and your heart stopped beating would you want to have someone perform cardiac massage on you in an effort to restart your heart '. The nurse should explain that the chances of a full recovery where the patient could leave hospital would be 5% (or whatever it would be). Then let the patient decide- they should be allowed to talk it over with relatives if they wish. They should also be told they may change their mind at a later date if they wish. This is exactly the kind of informed decision you would give a younger patient, so why not an older one?

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  • One of the biggest barriers to good quality end of life care is the Daily Mail and it's hysterical reporting of these matters.

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  • This is yet another symptom of the erosion of the district nursing team. Instead of small local teams of DN's who know many of the population in question we have moved towards large remote teams of less experienced nurses and a dilution in numbers of qualified DN's. Then we are given forms to fill and rules to follow to try to make up for lack of skill. In fact a never ending stream of you have to add this to your workload and do it yesterday. This to a service that doesn't have a full sign to stop any more admissions something has got to give. At the end of the day who treats us with compassion?

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  • End of life care, making decisions about CPR it all take time and recources.
    I agree the local nursing teams who know their patch are being diluted into just another post to be filled to get the work done.
    Nurses every where are under pressure, especially in elderly care where the work load is heavy,complex and a financial heavy for the NHS.
    Consultants are grumbling about elderly people being sent to hospital by GPs and Community nurses whose condition they cannot do much about. When some of these elderly get into hospital they are at Death's door & no CPR status done. Consultants and doctors are spending lots of time in speaking to next of kin and waiting for decisions which may take weeks. Nurses are spending a lot of their time on the elderly wards talking to NOK and the patient to help in the decision making while having to do a massive amount of physical & mental work. Other patients' care suffers when so much time is spent on talking.
    All Elderly Patients will benefit if a decision is made before going into hospital.
    GPs need to do much more to help in this matter.
    It is important though that DNR does not mean do not treat if something can be treated.

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  • michael stone

    Anonymous | 26-Aug-2014 8:44 am

    A lot in their I agree with - although 'next of kin' isn't the same thing as 'those close to the patient', and there isn't auromatically a role for 'next-of-kin' in this EoL stuff.

    There are many issues - but turning 'objectives' into 'tick-box' is one of the major problems.

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  • Patient choices, when healthy differ from those who have become ill. None of us want to be bed-bound, dependant or in a care home just now, whilst we enjoy the life-style that ability allows, but when we are in dire straights, we want to be helped not killed. This is the danger of advanced directives. Many who have been at the point of death and have recovered, will confirm this. It's natural to want to live and it OUGHT to be natural for a nurses to want to allow every patient the right to life, and the right for carers to do their best to bring the best quality of care to, give the best quality of life to their wards. Quality of life does not necessarily mean going off to the pubs, dances etc. Quality of life is loving and being loved by someone whose love doesnt depend on the other person benefiting them, but by being around. Those of us who have lost someone dear know how much we long to see them, be there for them, touch their hand, no matter what illness, incompetence they have fallen prey to. Every one should be allowed to have every possible means to help them live, even if they are old. That is what equality is about. NHS doesnt mind spending money of cosmetic surgery, treating diseases caused by foolish life-styles but the old, oh no, they are not worth investing is, yet they are the ones who have paid the mos into NHS, the ones who have fought for better health care, better living conditions and for our freedom. They deserve THE BESTG

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  • This will always be an emotive area for everyone involved.No-one likes to think about dying but unfortunately it is inevitable for us all.In response to some previous comments, this isnt about killing, if your body has stopped its own heart then something is very wrong and you are clinically DEAD.The question then is whether performing CPR is appropriate or a futile effort.There are some clinical conditions ie an aortic aneurysm where the outcome is inevitable, would you really put someone thru the indignity of CPR when you know there is no hope? We owe people the right to have control over there own life and death and not presume as a medical profession or relative that we know better! Life is about quality and every individual will have their own view on what that means for them.None of us want to loose a loved one, but loving someone is respecting there wishes even if it means letting them go.There is nothing more heartbreaking than your relative saying 'I wish i hadnt survived' when they realise that there life has changed beyond all recognition.
    I also think there is a lack of understanding in the medical profession regarding this, which causes unnecessary anxiety. I know of a case where someone signed a DNR after much dicussion with her GP and family, when she was admitted to hospital the consultant said the document wasnt valid in hospital and was asking her to consent again in a busy A+E department after just being in a diabetic hypo and sustaining multiple TIA's and wondered why she seemed unsure.If someone signs a DNR notice it needs to be a final decision, clearly more training is needed.

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  • Following on from one of the anon postings earlier that considers survival stats; for me there needs to be better quality printed information that spells out what the outcomes and chances of survival of resus actually are, especially for older people, and those who are frail and with complex needs. i deal with people quite regularly who think it will actually work for their 90-odd year old mum with 5 co-morbidities. if this information could be part of an interpersonal dialogue that was conducted compassionately this could really help the professionals who deal with this situation. if anyone knows of such information, please do post a link. if people do not get high quality information from us, then they will use the info they get from other sources (media including TV hospital soaps). This is tough work we do. x

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  • michael stone

    I've noticed a tendency for me to type 'their' instead of 'there' recently: this worries me.

    But I'm afraid this isn't solely about not attempting clinically pointless CPR. It is actually, about letting patients make their own choices about [uncertain] futures.

    Do patients change their views, as their situations change ? Yes.

    Do some 'terminal' patients actually recover ? Yes.

    But it isn't about those uncertainties - it is about patients making their own choices, after the clinical uncertainties have been explained to them.

    And, yes, not explaining to relatives, that 'your dad is so frail, that he will now die whatever we do' is an area fraught with problems. So is the possible 'rapid clinical deterioration of the elderly', which if NOT PROPERLY EXPLAINED to relatives, can [easily] lead to 'suspicions of murder':

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  • What exactly is a district nurse anyway?

    ANSWER: something old fashioned that doesn't reflect modern nursing

    Why has the need arisen for other community nursing services?

    ANSWER: commissioners, educationalists and sadly even DNs themselves didn't spot they needed to be anything different

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  • soon it will be mandatory for CPR to be carried out on all patients, unless told otherwise by the patient

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