Thursday, 28 April 2011

DNAR does not equate to DNT

Please read this article in the Colchester Daily Gazette.  It details a row that has erupted after Colchester PCT advised care homes not to automatically dial emergency services when a resident is dying.

I presume care homes in Colchester have become involved in the national drive to 'sign-up' en masse residents to Advance Decision to Refuse Treatment (ADRT).

Residents and relatives of those residents not deemed to have mental capacity are being coerced by Link GPs and indeed care homes (who wish to proudly boast they have achieved Gold Standard) to Advance Care Planning.

It has happened in my area with devastating results, many residents being highly offended and highly confused by this unrequested approach and relatives feeling pressured into making decisions they do not want to make.

What really concerns me about this article is that the family of Ellen Williams seem unclear as to exactly what they have signed, believing that she has been "put on the Liverpool Care Pathway "do not resucistate" plan."  What is this?  Clearly from the article she (Ellen) is not "on" the LCP - but clearly, her future (lack of treatment) is well mapped out.

I can only assume that the link GP discusssed placing Ellen on the LCP when she is in the process of dying and during this discussion the family requested or agreed to Do Not Attempt Resuscitation (DNAR).

However, it is important to state that DNAR decisions only apply to CPR (cardiac massage and artificial respiration) and not to any other aspect of treatment - such as comfort measures: antibiotics, analgesia, hydration and feeding (any route), oxygen, hospital admission and suction.  DNAR does not mean Do Not Treat (DNT).

Four residents in my home have ADRTs in place - three requested by relatives when their loved one was 'in the process of dying' and the fourth when the GP requested to see the relatives for the same reason.  All have a DNAR in place, relatives have requested no hospitisation for two of these residents and all relatives have requested active treatment should their loved ones become ill.  All of these residents are still alive!

So the question needs to be asked that if the GPs were wrong in these instances why nurses are deemed to have the skill of recognising 'dying' when it suits a PCT.  If I am concerned about the health of a resident - something which can't wait until a GP visit in the morning - I phone Out Of Hours (OOH) Services and often, when giving details I am informed that I should contact emergency services - because they can't be arsed to come out!  If I felt emergency services were required I would have done this.

Of the four residents mentioned previously, if thought required, I would contact emergency services for two of them.  The remainder I would contact OOH.  Nursing home nurses are between a rock and a hard place - with regards to requesting GP input - they are damned if they do and damned if they don't!  I will not take risks with a residents life - I am not a doctor.  Woe betide me if I sat by and did nothing should a resident become critically ill - I am a hundred percent certain no PCT or GP would back me up!  I would be hung, drawn and quartered!

I am concerned re Dr Shane Gordons statement, feeling he has totally missed the point that there is a lack of clarity, a lack of understanding of Advance Care Planning and an unawareness of the ramifications of signing same.

I wonder if he has read "This paper desribes the protocol of a multidisciplinary study that will provide timely and essential insights into an area of end of life care, ACP, which has become policy driven within the UK despite a weak evidence base." 

Advance/Anticipatory Planning (formerly Living Wills) is fine and dandy if it is a choice you make yourself.  If I had a terminal illness - I would request and sign one myself.  Okay dementia is terminal, but it is not a tomorrow thing.  Until it reaches end-stage you have a right to treatment.

We all get old some day - even doctors and those who manage PCTs.

Anna :o]


Dave King said...

Another step back to 1984?

HyperCRYPTICal said...

Indeed it is Dave. The older we become - the more we are viewed as a burden on society and the more dispensable we become.

Anna :o]

Julie said...

Yep, I remember a while back an article about Hammersmith Hospital. They were handing forms to people as they went in for treatment and they thought it was for cardiac resuscitation. The patients didn't realise it also applied to providing drips and nutrition. The good old Mental Capacity Act struck again. Btw, one of the Hammersmith trustes has just been done for fraud as well.

HyperCRYPTICal said...

Did a bit of research Julie and couldn't find anything re Hammersmith Hospital - but can well believe it.

One relatively young resident attending A&E was asked if she wanted resucitation should she die and she said "No." A few minutes later when realising what she had been asked, quickly changed this to a "Yes!" What would have happened (in her then vulnerable state) if she hadn't realised what she had said "No" too?

I did find stuff relating to the fraud. Also learned that in 2008-9, NHS Counter Fraud Services achieved potential savings of £9,946,030 following prosecution in 69 criminal cases!

Being a NHS manager does have its perks - as long as you are don't get caught!

Anna :o]

Julie said...

I'll have a look for it. It was about five years ago, so might be tricky to find, but it definitely happened. Worrying stuff. The Scottish Patients' Association is dealing with a lot of stuff relating to the LCP up here as well.

ned ludd carer said...

We've done an end of life plan for my son, with help from one of the care providers and the PCT. Involved us, him and all his nursing team. A hard process but glad we did it. They now understand why CPR would be inappropriate - it would cause so much damage he'd get little more time and lots more pain (shape of spine, lungs etc.) and it probably wouldn't work for him anyway. Having said that, they understand about day to day care being essential. What worries me isn't his nursing team - it's if he goes into hospital with people who don't understand him. This is partly why we avoid hospital admission at all costs. Even with a communication passport and pre-written care protocols agreed, every experience we've had of hospital with him has been a nightmare in practice. Insufficient staff, not trained in disability, well meaning but under too much pressure and nowhere near enough nurses usually results in us discharging him as soon as he's well enough to be moved.
Rant over.

HyperCRYPTICal said...

Hi Ned

I can understand why you have an end of life care plan for your son as you know him well and understand the futility of CPR in his particular case.

I can understand your fears too in the event of your son being hospitalised. With staff shortages, etc it is difficult to achieve any personalised care and the problems you face with staff not trained in disability is an added burden for you.

To a lesser extent - the same problem is faced in those with dementia - a lack of understanding of the needs and abilities of the sufferer. We fear for our residents when hospitalised and several relatives - apart from those mentioned in the post, request that in the event of illness - their loved one stays in the home.

We always send a detailed history of medical problems and all aspects of the residents abilities and needs with reference to daily living when they attend A&E - but it is a rare occasion for this info package to be transferred to the ward with them.

Rant as much as you want, my friend.

Anna :o]

ned ludd carer said...

One thing that has helped is a 'communication passport' These are becoming more common for people with a learning disability, take a standard format and briefly describe care needs and other critical information. They don't work in all circumstances but do give carers something to justify what is needed when things look like they are going awry. They've helped us get sensible care protocols for medication etc. when in hospital etc.. May be helpful elsewhere for vulnerable but less articulate people.