‘Do not resuscitate’, and the consequences of not following it

Imagine … you are attending to a resident one day, and you suddenly find them unresponsive and not breathing.

You believe the resident has a ‘do not resuscitate’ (DNR) order in place, but it’s not documented on your handover sheet and you have to make the critical decision to either;

• leave the resident whilst you go and find the correct documentation somewhere in their file
• or stay with the resident and begin CPR, so that you don’t waste time while you deliberate.

You know that a delay in commencing CPR can have a critical impact on the overall outcome for the resident.

This is an issue that nurses and aged care workers are faced with more often than you would expect. Yet frequently the wishes of all residents living in facilities are often not widely known or adequately communicated to key staff working on the floor.

If you’re an agency nurse then it’s even less likely you will have this information on hand when you need it.

The topic recently was raised through HelloCare’s Aged Care Worker Support Group, and the responses reveal the highly complex nature of these decisions and the uncertainty about what should occur in this situation, and many others like them.

Members have written of residents being resuscitated even when a DNR order is in place, and the family and the resident (after he survived) came away angry and disappointed he was put through such heroic measures.

Others have revealed the stress of not being able to access the right paperwork, and therefore DNR orders can not be enacted upon urgently.

These are complex issues, and no single situation is the same. Some facilities of-course doing it better than others.

Every aspect has to be weighed and considered, and the circumstances thought through. While aged care isn’t a hospital, perhaps there are some learnings that can be taken away from the acute setting when it comes to documentation.

We take a look at DNR orders and try to provide some answers.

What is a ‘do not resuscitate order’?

A DNR order is a medical order to withhold cardiopulmonary resuscitation (CPR).

Such an order lets the healthcare team know that, in the event of a cardiac arrest, CPR must not be conducted. Instead, healthcare staff should promote comfort and prepare for end-of-life care.

It is widely recommended that all families with aging parents or loved ones talk about what to do in the event of a serious or terminal event or illness, and document your decisions so that they are legally binding.

Other terms used to describe DNR order include:

• No CPR,
• NFR (Not for resuscitation),
• NFAR (Not for attempted resuscitation),
• DNAR (do not attempt resuscitation), and
• AND (allow natural death).

Open and unambiguous communication between the relevant parties takes place, both in determining to put one in place and in communicating it to loved ones and the healthcare team.

Ethical and professional considerations

In an emergency, CPR, like other types of treatment can be provided without consent, unless there is a valid written directive to the contrary (NFR or advanced care directive)

One of my colleagues reported their own experiences of when the ambulance attended an aged care home, and they found themselves in a position having to start CPR as no-one could produce a DNR order of a resident that they believed didn’t want to be resuscitated.

So how is it that frail elderly people who’ve expressed their wishes not to be resuscitated are still subjected to such an undignified nightmare?

Clearer communication surrounding DNR needed

DNR orders have been around since the 1970s, yet there remains many difficulties in how DNR decisions are put into practice, including the use of consistent and clear documentation in progress notes/medical records to ensure everyone in the home is across the resident’s decision.

Clearer, easy to find documentation during an emergency seems to be lacking despite the digitisation occurring in patient monitoring and software.

The harsh reality of resuscitation

CPR itself can injure people, especially the frail or old. CPR requires someone to push on a person’s rib cage with enough force to pump blood around the body.

The force used often cracks ribs. But even worse, it can lead to brain damage if the person’s heart has stopped beating for a long enough period. As a result, the person might live for days and weeks in an undignified way, only to succumb to death eventually anyway.

Without the right circumstances, return to the default position

Despite the difficulties of CPR, healthcare professionals can not simply withdraw care. Strict guidelines exist around DNR orders.

Linda Nolte, program director of Advance Care Planning Australia, told HelloCare that aged care providers must have “robust systems, processes and training in place that support quality end-of-life care”.

Valid DNR orders and advance care directives are legally binding and should be enacted.

“All relevant advance care planning documents should be accessible to everyone involved in the care of the individual. This provides clarity for all involved in the care of the individual and ensures that their wishes are known and respected,” Ms Nolte said.

But when the necessary documentation is not available, DNR orders can not be enacted, and herein lies the solution to the problem we outlined at the beginning of this article.

Ms Nolte said, “If relevant documents are unable to be accessed, then the default position is that the care worker would attempt to resuscitate the individual.”

Providers have the duty of care to ensure that inappropriate resuscitation to residents doesn’t happen.

This article is a guide only and should not be considered medical advice.

Image: Kaipungyai, iStock.