In the Midst of Life

linked to an address where a palliative care patient lives, so if an emergency call is generated for that person, theinformation is passed to the crew that the patient is not to be resuscitated.
    Indeed, this facility also extends to GPs and hospital consultants who have patients who have requested DNAR for a variety of conditions – COPD (like my mother), advanced Alzheimer’s, Parkinson’s, or any other illness or condition where CPR is deemed inappropriate. The only thing we require to enable us to safeguard ourselves is the sight of the original unaltered document that is signed by the doctor on arrival at the call.
    These DNAR documents have no expiry date and, once signed, are valid until the patient dies or the order is changed for whatever reason.
    DNAR in most cases would refer to CPR only, but also has the flexibility to allow withholding other treatment such as artificial nutrition and hydration – although these treatments tend to apply to patients already in hospital. Other ambulance services are working around the Allow a Natural Death (AND) procedure.
    What is encouraging, of course, is that the ambulance service is now very much part of the integrated multi-disciplined team, and is consulted by the various primary care trusts in end-of-life care issues; and our concerns and wishes are being registered and used, helping us all with the treatment and services we can offer to patients as they reach the end of their natural lives.
    What the future holds
    Advancement in training, education, and the ever-increasing policies and protocols we follow now, will no doubt lead to an older, and healthier, nation. It is an amazing fact that treatments that we currently use already lead to heart attack and stroke patients recovering fully and going back to ‘tax paying’ status in a few short weeks. Twenty years ago, these patients would have died, or become paralysed for the rest of their lives.
    I often chat with my work colleagues and ask them the searching question, ‘Have you thought about how and where you would prefer to die?’
    I am surprised that most of them haven’t even thought abouttheir own death, or what their personal preference is. This alarms me, considering the amount of death we actually deal with in our line of work!
    For my own part, should I be suffering from an incurable illness, I will be instructing my GP and get my own DNAR written out, and I will leave it in a big white envelope just by the front door - in the hope that the young, keen ambulance crew who come rushing in will take note, and leave me to die in the peace I hopefully have earned!

APPENDIX III
     
    Shouldpatients at the end of life be given the option of receiving CPR?
     
    by Madeline Bass, BSc, RGN, Head of Education, St Nicholas Hospice, Bury St Edmunds, Suffolk
     
    First published in
Nursing Times;
105 4, 26-02-2009.
     
    Cardio-pulmonary resuscitation (CPR) is often unsuccessful and may not always be appropriate at the end of life. This article debates whether the use of cardio-pulmonary resuscitation by healthcare professionals in situations when it is unlikely to be successful feeds an unhealthy appetite to intervene just because it is possible. It explores the problem of offering patients and relatives the choice about CPR at the end of life when it is likely to be unsuccessful.
    End-of-life and palliative care has become an increasingly important area of healthcare professionals’ work following publication of the End of Life Care Strategy (Department of Health, 2008).
    Good communication between patients and staff is essential for those who are making choices and decisions about care at the end of life. This may include discussions about cardio-pulmonary resuscitation.
    We can now treat disease and disability in ways that would not have been thought possible sixty years ago. These achievements have also created bioethical dilemmas. The advent of new treatment interventions has brought its own unhealthy appetite - the more treatments healthcare workers have to offer, the more they intervene. To them, this equates with doing the best for patients and knowing that everything has been tried.
    However, in some cases, interventions can mean poor outcomesfor the patient and result in low staff morale. One area of particular concern is the decision about when it is appropriate to perform CPR.
    Misconceptions about CPR
    The media’s interpretation of CPR, primarily through TV drama, has led to a misunderstanding