Ethical questions - capacity and DNR

[Banjomansmate]

This subject has popped up with me just recently.
My neighbour with, probably mid term dementia, had an accident at home last week and was taken to hospital by ambulance. Her family with LPA told the ambulance crew that she had DNAR registered with her GP so if she crashed on the way to hospital to let her go.
Now as far as I am aware, the idea of having DNAR registered with your GP was that the ambulance crew had access to your records through their computer and it would come up and they would know what not to do. This would then be passed on to the hospital.

When she was fully cognisant with her own health problems my neighbour told me that should I ever find her crashed out I was NOT to call an ambulance, or if I did I was to make sure they didn’t attempt resuscitation!
She now has no idea of her limitations, her family need to support her as her cognition is disappearing and she is only just managing to live by herself. Last week she came to me with a horrific looking injury. She had no idea how it had happened and didn’t even seem to feel any pain. I called the ambulance and her family and then left them to it!
Now to the ethics question and the point made by @Cap'n Grimm about do you respect a person’s wishes if they have lost capacity to understand what is happening to them?
On reaching hospital this nearly 90 year old lady with dementia and no understanding of her own physical and mental frailty was asked that if her heart stopped did she wish to be resuscitated ?
She said “Yes”! So they did, twice!

Would you say that was ethically right? Because frankly I think that is dreadful. All that is going to happen is that she will now be left to suffer what I suspect will be a long drawn out healing process, she is unlikely to be able to return to her own home and will just deteriorate until she dies. This is against all that she stated and wished for when she had full capacity and as a nursing sister she knew exactly what she was talking about.
So, what is the point of GPs asking if their patients wish for DNAR to be on their records if that information isn’t instantly available to hospitals, or they ignore it if it is? And should hospitals not check on the mental capacity and understanding of elderly patients before asking them a leading question ?

 

[sdmhred]

What an awful situation @Banjomansmate

Ambulance crews sadly cannot access GP records - far too much for the big NHS computer to manage.

The advice with DNAR is to have it or a sign saying where it is on your fridge door. That is where the crew will look for it if they find someone on their own who can’t communicate.

Im surprised she was asked that question on admission….in my previous experiences we have been asked is DNAR in place on admission which would have been yes for that lady. From your description she lacked capacity to answer.

When mum was blue lighted in I heard the crew on the phone to A&E say next of kin on board and DNAR in place.

So we say you can lack capacity to make a health decision and ur POA / Dr’s act for you…..

But do we now therefore also say Dorothy also lacks capacity to make the choice to pick up the non vegan custard cream? What a mine field.

And as we’ve noted we live in a practical world. We can refrain from CPR but a care home can’t stop Dorothy reaching for the biscuit …..and down other legislation that would be considered abuse 🤯🤯🤯

 

[Lawson58]

This subject has popped up with me just recently.
My neighbour with, probably mid term dementia, had an accident at home last week and was taken to hospital by ambulance. Her family with LPA told the ambulance crew that she had DNAR registered with her GP so if she crashed on the way to hospital to let her go.
Now as far as I am aware, the idea of having DNAR registered with your GP was that the ambulance crew had access to your records through their computer and it would come up and they would know what not to do. This would then be passed on to the hospital.

When she was fully cognisant with her own health problems my neighbour told me that should I ever find her crashed out I was NOT to call an ambulance, or if I did I was to make sure they didn’t attempt resuscitation!
She now has no idea of her limitations, her family need to support her as her cognition is disappearing and she is only just managing to live by herself. Last week she came to me with a horrific looking injury. She had no idea how it had happened and didn’t even seem to feel any pain. I called the ambulance and her family and then left them to it!
Now to the ethics question and the point made by @Cap'n Grimm about do you respect a person’s wishes if they have lost capacity to understand what is happening to them?
On reaching hospital this nearly 90 year old lady with dementia and no understanding of her own physical and mental frailty was asked that if her heart stopped did she wish to be resuscitated ?
She said “Yes”! So they did, twice!

Would you say that was ethically right? Because frankly I think that is dreadful. All that is going to happen is that she will now be left to suffer what I suspect will be a long drawn out healing process, she is unlikely to be able to return to her own home and will just deteriorate until she dies. This is against all that she stated and wished for when she had full capacity and as a nursing sister she knew exactly what she was talking about.
So, what is the point of GPs asking if their patients wish for DNAR to be on their records if that information isn’t instantly available to hospitals, or they ignore it if it is? And should hospitals not check on the mental capacity and understanding of elderly patients before asking them a leading question ?

This brings up the idea of an Advanced Planning Document which everybody should have. Mine has statements about what will happen should I develop dementia so deals with those issues without anyone needing to ask me.

My Advanced Planning Document is legal and cannot be overridden by doctors so that deals with that problem. My GP, my local university hospital and my decision makers all have copies so everyone should know what is required.

When I was having my cataracts done at a different hospital, they asked me to provide a copy of my Advanced Planning Directive at the time I was being admitted.

My experience is that here in Australia, doctors are weighing up whether there will be any benefit to a patient in the long term to provide major interventions or if the procedures will cause major distress to the frail or desperately ill whose prognosis is already poor.

Two easy books to read ’Letting Go’ by Dr Charlie Corke 2018 pub. by Scribe, and ’A Good Life to the End’ by Ken Hillman 2017 Allen and Unwin. Both are easy reads and non technical.

I have no idea of how to post a link but this opinion piece by Prof. Neil Orford might be of value. Neil is one of my biggest heroes who spent time with me when my husband had his cardiac arrest.

 

[nitram]

The advice with DNAR is to have it or a sign saying where it is on your fridge door. That is where the crew will look for it if they find someone on their own who can’t communicate.

There's a national scheme run by Lions Clubs eg

Welcome to the READING LIONS CLUB (CIO)

Charity support in the Reading community

www.readinglions.org.uk

 

[Banjomansmate]

Well, I know she had one of those because I gave it to her (I have one myself). With her dementia she could well have thrown it out, she’d unplugged her phone and emergency call system so couldn’t contact her family. Luckily I had my mobile on me, usually I have to look for it!
But the thing is, her family with LPA were also ignored by the hospital, despite telling the ambulance crew about the DNAR.

 

[sdmhred]

Yes, that was wrong @Banjomansmate - I would probably be following that up with the hospital if I was the family. It must have been a very enthusiastic or young doctor to ignore the DNAR on someone that old and then do the resus 🤷‍♀️🤷‍♀️🤷‍♀️

 

[northumbrian_k]

My wife is in a care home and has an Emergency Care Plan (ECP) that specifies no hospital admission and being made comfortable in her home. Despite that she was taken to hospital for investigation on the advice of paramedics. She was accompanied by a senior carer and a paper copy of the ECP. I was present for the consultation with the junior doctor and spoke on my wife's behalf Referring to the Plan, the doctor rightly questioned why we had attended. After checking with a senior colleague he said that doing blood tests (a minimally invasive procedure) was pointless and probably unethical as no treatment would be given. I was in total agreement.

 

[canary]

I think that where it comes to following DNAR, ECP and RESPECT plans, many health professionals are afraid of being accused of neglect and being sued if they dont do everything they can to preserve life. Several high profile court cases have reenforced this feeling. When mum had a stroke I talked to the consultant and, although mum had a DNAR in place, I got the distinct impression that he was relieved when I said that I did not think it appropriate for someone in advanced dementia to have stents inserted etc.

 

[Lawson58]

I think that where it comes to following DNAR, ECP and RESPECT plans, many health professionals are afraid of being accused of neglect and being sued if they dont do everything they can to preserve life. Several high profile court cases have reenforced this feeling. When mum had a stroke I talked to the consultant and, although mum had a DNAR in place, I got the distinct impression that he was relieved when I said that I did not think it appropriate for someone in advanced dementia to have stents inserted etc.

I must say that when I watch British TV programs such as ’Emergency’ I am always surprised how everyone asks permission to do anything and everything.

I think that with children that it is a good idea but it seems to use a lot of precious time for adults. I believe that patients need to understand what people are doing to them but to seek permission for some quite minor things seems a bit unnecessary. Major procedures are a different thing.

 

[2ndAlto]

I have heard of people getting DNR tattooed on their chest...I could get one to go with my radiation tatts...

I did look at the Advanced Health Directive @lawson but when contemplating it I lost the will to live. Far too complicated.

 

[Lawson58]

I have heard of people getting DNR tattooed on their chest...I could get one to go with my radiation tatts...

I did look at the Advanced Health Directive @lawson but when contemplating it I lost the will to live. Far too complicated.

I did mine through our local hospital who had a free service that was really helpful. One of the people who helped me had been an ICU nurse for seventeen years which is why she wanted to work in this area.

It was my husband’s cardiac arrest at home followed a few months later with a dementia diagnosis that brought me to the place of an Advanced Care Directive.

I really thought it would be confronting but I started by using the www.myvalues.org.au website which made things much easier than I ever thought it could be. This led me to a site that translated my answers into a document that was the basis for the directive.

The reality is that I felt that I was now in control of the medical issues that we have to face as we age and that made me feel heaps better, reassured I think.

More importantly, I wanted to relieve my children as my decision makers of having to make a call without knowing exactly what I would have wanted. They do anyway but being a legal document, they can pursue that decision with authority, no guilt attached.

When my directive had been completed, I bought the brightest folders I could find and decorated them with all sorts of ribbons and stars so you could never mislay them. I gave them to my children with the instructions to go home and read them.

In spite of all the things that have happened in the last few years, the directive has given me a sense of security and self confidence and I am pleased that I did it.

 

[2ndAlto]

I did mine through our local hospital who had a free service that was really helpful. One of the people who helped me had been an ICU nurse for seventeen years which is why she wanted to work in this area.

It was my husband’s cardiac arrest at home followed a few months later with a dementia diagnosis that brought me to the place of an Advanced Care Directive.

I really thought it would be confronting but I started by using the www.myvalues.org.au website which made things much easier than I ever thought it could be. This led me to a site that translated my answers into a document that was the basis for the directive.

The reality is that I felt that I was now in control of the medical issues that we have to face as we age and that made me feel heaps better, reassured I think.

More importantly, I wanted to relieve my children as my decision makers of having to make a call without knowing exactly what I would have wanted. They do anyway but being a legal document, they can pursue that decision with authority, no guilt attached.

When my directive had been completed, I bought the brightest folders I could find and decorated them with all sorts of ribbons and stars so you could never mislay them. I gave them to my children with the instructions to go home and read them.

In spite of all the things that have happened in the last few years, the directive has given me a sense of security and self confidence and I am pleased that I did it.

Thanks that's very helpful