In the Midst of Life

demanded.
    Do Not Attempt Resuscitation
    If a heart attack is treated promptly with defibrillation, and if other emergency treatment prevents damage to the heart, the patient can often return to a normal life and have a normal life expectancy. Clearly resuscitation in this circumstance would be worthwhile. On the other hand, if a patient with an advanced disease, such as terminal cancer or terminal lung failure, develops a sudden lethal cardiac rhythm disorder, successful resuscitation might result in limited benefit, such as survival for a few more days or weeks, potentially in the context of receiving intensive medical care. Many people would regard this second example of resuscitation as futile, or of limited value. Between these two examples are many shades of grey, and it is good medical practice to try to establish the likelyvalue or futility of emergency resuscitation in each patient during acute illness or admission to hospital. It is also good medical practice to try to think about the likely value of undertaking emergency resuscitation if someone has a chronic progressive and untreatable condition.
    A discussion about the benefits or futility of resuscitation can be difficult for someone if they have not considered the matter beforehand, particularly in the case of a newly diagnosed acute illness with limited treatment or with a grave prognosis. On the other hand, most people will want to talk, learn about and discuss their illness, especially when they are anxious or frightened. Talking about the prognosis should be a natural part of the discussion, although doctors often do not raise the subject of death if patients do not ask, and patients can be too uncertain or too frightened to ask. In my experience most people prefer quality of life to longevity but occasionally people will want to keep going for a specific reason even if they are very unwell, such as a family event like the wedding of a son or daughter, the birth of a grandchild, or the completion of an important project.
    Questions about resuscitation are not usually a simple yes or no decision. For example, most people who are not in an advanced terminal illness would want to be resuscitated from a simple cardiac rhythm disturbance or from transient difficulty in breathing due to infection, but often would not want prolonged intensive care with supportive treatment on an artificial ventilator or on kidney dialysis. Thus, any clinical discussion of resuscitation should include what types of resuscitation might be undertaken, and how far-reaching these directives might be. If the conclusion is that the person does not want to be resuscitated from their current illness, then this wish must be respected, and a note or statement made in their medical records to this effect. This statement should be as precise as possible, for example: ‘this person does not wish to be resuscitated from a cardio-respiratory arrest’. When patients have decided that they do not wish to be resuscitated, almost all hospitals have specific ‘Do Not Attempt Resuscitation’ (DNAR) forms for completion by an experienced doctor. There is a model DNARform, as well as a model patient information leaflet, available on the Resuscitation Council website. * Most hospitals also have a resuscitation committee, which will agree local policies on the application of Do Not Attempt Resuscitation decisions, and audit the appropriateness of these orders.
    It can take a considerable amount of time for doctors to explain resuscitation issues to patients, and for clinicians to understand the wishes of the patient - such discussions are usually sensitive, exploratory and wide-ranging, and often require several conversations. Modern hospital practice usually involves shift work, and often there are several different doctors looking after each patient. It is essential that the clinical team makes time to discuss resuscitation decisions with each patient, and that there is a consistent response from each clinician.
    Almost every hospital has introduced Do Not Attempt Resuscitation policies, procedures and forms, and clinical staff have become better at discussing death and resuscitation with patients. For those involved in hospice care and palliative care teams, however, the management of death goes well beyond the issue of whether to resuscitate or not. An alternative, more positive way of thinking about death in people with advanced disease is labelled Allow a Natural Death’ (AND). †