End of life and treatment escalation discussions

‘Do Not Attempt CardioPulmonary Resuscitation’ (DNACPR) discussions

Background information 

• Decisions regarding CPR are ultimately taken by the patient’s medical team. A patient can refuse CPR but cannot demand it. 
• Success of in-hospital resuscitation is around 20% but this may be much lower if there are comorbidities/reasons why it is less likely to be successful. Of those who survive resuscitation, only around half will make it out of hospital.
• A DNAR form may be completed for one of three reasons:
  • Resuscitation is unlikely to be successful
  • The patient does not want it
  • It may be successful but would result in a length and quality of life that is not in the patient’s overall benefit 
• If a patient has capacity, they should be informed of the decision (unless it will cause significant physical or psychological harm)
• If a patient does not have capacity, the relatives of the patient should be informed
• All DNAR discussions should be clearly documented
• ‘Do Not Resuscitate’ does not mean stop treatment
• If the form is signed by a junior doctor, it should be countersigned by a consultant as soon as possible

Approach

• It is usually best brought up during a wider discussion about advance care planning
• Work your way up to it rather than jumping straight in. Try to build rapport and start by discussing current problems and how they are being treated.
• Explain there is always a risk that things might get worse and the patient might deteriorate 
• Explain what CPR is and what it involves 
• If CPR would not be successful, sensitively explain why your team feels it would not be appropriate. If CPR might be successful, discuss the patient’s wishes and feelings. Try to determine whether the benefits would outweigh the risks and burdens; and if the level of recovery would be acceptable to the patient.
• Stress that a DNAR decision does not mean that the patient will not be treated – it is only relevant if their heart stops
• Do not ask the patient or relatives to make the decision 
• If the patient/relatives strongly disagree, don’t force it – escalate the discussion to your seniors or ask for a second opinion 

Phrases to help

• ‘One thing that it is important for us 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 appropriate to ensure he is not in any pain or distress in the last moments of his life. If it were to get to the point where his heart stopped, we would not try to restart it.’
• ‘We will still give her 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 it, because this can cause a lot of pain and distress, and prolong suffering.’
• ‘His medical condition means that he will eventually get to the natural end of his life and it is important we talk about this before it happens. Trying to restart his heart in this situation would not be the right thing to do.’
• ‘We only have one chance with end of life care so it is important to get it right.’
• ‘Even if a patient survives resuscitation, they are often more disabled afterwards, and left with a quality of life that they would not want.’

Other treatment escalation decisions

• In addition to decisions regarding resuscitation, decisions should also be made about other invasive treatments where appropriate. These should be documented in the patient’s notes and on a treatment escalation plan document.  
• The patient can only insist upon things they do not want
• It is for doctors to decide which treatments are and are not appropriate, e.g. intensive care admission, non-invasive ventilation, parenteral nutrition etc.
• Factors to take into account when considering intensive care admission include:
  • Diagnosis, severity of illness and prognosis: to warrant intensive care admission, a patient must have an acute reversible condition and a viable treatment must be available
  • Age, comorbidities and physiological reserve: surviving intensive care and invasive treatment requires a good physiological reserve (e.g. there is no point ventilating patients who will not be able to get off the ventilator)
  • Anticipated quality of life: there is often a physiological decline after severe illness and it is important to consider if the patient would be left with an acceptable quality of life
  • Patient wishes: if a patient does not want invasive treatments, then their choice should be respected. If the patient cannot communicate this, it is important to speak to their family about what their wishes would have been.

Explaining to relatives that a patient is at end of life

Approach

• Use a breaking bad news approach (see notes on breaking bad news)
• Explain to the family you will involve the palliative care team if required, and offer spiritual support where available, e.g. chaplain
• Ensure you talk about the patient’s symptoms and reassure them that they can be managed

Phrases to help

• ‘We have tried giving strong antibiotics, fluids and oxygen but he has not made any improvement at all.’ – PAUSE 
• ‘I am afraid, he is not going to recover from this and he is now in the final stages of his life.’ – PAUSE 
• ‘We believe further invasive treatment and tests will prolong his suffering and will not make any difference.’
• ‘The most important thing now is for us to concentrate all our efforts on making sure he is comfortable and not in any pain or distress.’

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Consent for post mortem

Background information 

• Types and refusal
  • Coroner’s post mortem: the relatives cannot refuse this (it must be carried out by law)
  • Consented post mortem (for educational purposes): written consent required from next of kin
• A consented post mortem is usually performed when the cause of death is already known. The purpose is to learn more about the condition or effects of treatment, and to help better manage other patients in the future.
• It is done in a respectful manner 
• Incisions will be hidden by clothes/hair
• All tissue will be replaced inside the body unless required by the coroner or specified on the consent form
• It takes around 3 hours
• It is usually done within 2-3 days so funerals need not be delayed 
• The report will be sent whoever requested the post mortem. The relatives will be informed of the cause of death and can request the full report if required for a fee. They can arrange to meet the consultant or GP to discuss the results, which will contain medical terminology.

Approach

• Be respectful and always start by saying you are sorry for their loss 
• Ask them how much they know about what happened and what caused the death
• Coroner’s post mortem: explain that when it is not clear what has happened, we have to notify the coroner, and that in some circumstances they order a post mortem (remember you may be breaking bad news). Explain why it is important to establish the cause of death.
• Find out what their concerns about post mortem are – they may not understand or have misconceptions about what is involved

Brainstem death

Background information 

• Brainstem death = irreversible loss of all brain and brainstem function
• It is confirmed by two qualified specialists who do a series of tests independently to assess brainstem reflexes and breathing

Approach

• Use a breaking bad news approach
• Explain the patient is dead, despite the machine making it look like they are still breathing
• Explain that two senior consultants have done multiple tests to confirm the patient is dead
• Explain that we should now turn off the ventilator 

Organ donation

Background information 

• Patients cannot donate if they have HIV, Creutzfeldt-Jakob disease or metastatic cancer
• Consent can be from the patient or relative
• If a patient has clearly consented before death, the relatives do not have the legal right to override the decision
• If a patient has not consented before death, consent from relatives is required

Approach

• Explain what organ donation involves
• Explain the benefits 
• Reassure relatives about funerals and the fairness of organ allocation
• If the patient has not expressed a wish to donate, find out what they would have wanted

Test your knowledge

What are the three types of organ donation?

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Can a patient’s next of kin refuse a post-mortem?

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Which grade of doctor can sign a DNAR form?

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How long is a DNAR form valid if it is signed by a non-consultant doctor?

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