This question comes from ‘… a community support worker I am caring for a patient who has a “Do Not Resuscitate” order’. They ask
If this client becomes unconscious what should I do?
Start CPR because I am not a medical professional and can’t make those decisions or just make client comfortably until ambulance arrives and handover the DNR document for them to decide?
Just wondering if there is a straight forward answer to a DNR.
There is a ‘straight forward answer’ and what is worrying is that a person who is working as a ‘community support worker’ hasn’t been trained by their agency on how to deal with this matter.
First let me say that I am assuming that the DNR documentation has been seen and it should be copied into the client file. I’m also assuming that the DNR documentation has been signed off with at least the knowledge of the client’s family.
Where a person needs CPR, the legal justification is necessity – see The Doctrine Of Necessity – Explained (January 31, 2017). The relevant quote, taken from the case law, is the quote from Lord Goff in In Re F  2 AC 1:
The basic requirements, applicable in these cases of necessity, that, to fall within the principle, not only (1) must there be a necessity to act when it is not practicable to communicate with the assisted person, but also (2) the action taken must be such as a reasonable person would in all the circumstance take, acting in the best interests of the assisted person.
On this statement of principle, I wish to observe that officious intervention cannot be justified by the principle of necessity. So intervention cannot be justified when another more appropriate person is available and willing to act; nor can it be justified when it is contrary to the known wishes of the assisted person, to the extent that he is capable of rationally forming such a wish.
Where there is DNR documentation completed with the client’s consent, CPR can’t be justified. We usually think CPR is in the patient’s best interests and someone who has suffered a sudden cardiac arrest would rather live than die. A person who is approaching the end of their life has to face that reality and may have decided that given the underlying conditions – whether it’s a terminal illness or just the manifestation of old age – that CPR is not in their best interests. If that is the case and they have recorded that in consultation with their doctor and family, we know that CPR is NOT in the patient’s best interests. In that case commencing CPR on a person who has gone to the effort of recording their wishes on a DNR document is NOT ‘action … a reasonable person would in all the circumstance take, acting in the best interests of the assisted person.’
Secondly, regardless of best wishes, if the person has indicated that they do not want CPR, then the treatment cannot be justified as it is ‘contrary to the known wishes of the assisted person’ (emphasis added).
DNR documentation can also be completed without the consent of the patient if the treatment will, given the person’s conditions, futile. There is no obligation to provide treatment that will not advance the patient’s best interests or achieve a therapeutic outcome (Airedale NHS Trust v Bland  A.C. 789].
If the patient is unable to give consent to the DNR order then it must be made by the medical team and family acting in the best interests of the person in need of care. Again, if that has been done and recorded, a care worker should not commence CPR as that is NOT ‘action … a reasonable person would in all the circumstance take, acting in the best interests of the assisted person.’
As a community care worker who honours DNR documentation you are not making decisions, you are giving effect to decisions that have already been made.
If you are not willing to honour a DNR decision, one has to ask ‘what is the purpose of consent in medical care?’ People are allowed to make decisions about their care even if it will lead to their death. If we are not willing to honour that, if we are going to assist that people receive treatment whether they want it or not, we are going back to paternalistic health care, or worse. What’s worse is that people provide care, like CPR, not because it is in the patient’s best interests but because it makes the carer feel better or more comfortable. Health care is not (or should not) be provided in the best interests of the care provider but in the best interests of the person in need of that care. Where DNR documentation has been completed the inference is that the interests of the person have been considered and it’s been determined that withholding CPR is in the patient’s best interests.
In some states, there is statutory protection to ensure people that honour DNR type documentation are legally protected (see for example Advance Personal Planning Act 2013 (NT) and Medical Treatment Act 1988 (Vic)). Even where that is not the case the common law still applies to say that people are entitled to refuse consent and that futile treatment may be withheld.
One has to concede that is unlikely a community support worker will be sued or prosecuted for battery for doing CPR but if one is planning to provide care in the client’s best interests and in accordance with the client’s wishes, providing treatment contrary to the terms of a DNR decision is unethical and will expose the client and their family to unnecessary and undesired trauma.
As noted earlier, what is worrying is that a person who is working as a ‘community support worker’ hasn’t been trained by their agency on how to deal with this matter. If support is being provided to a person who is terminally ill or otherwise likely to require CPR, such that decisions have been made to withhold that treatment, the the agency should have procedures to ensure that DNR decisions are recorded and communicated to carers. If necessary discussion should be had with the client, their family and their medical practitioner to ensure that the terms and consequences of the documentation are clear and clearly understood. And staff who are providing care have to be confident to honour their client’s wishes. If that isn’t occurring I would worry about the conduct of the agency that is providing ‘community support’.
No wonder there is a need to ‘register’ so-called ‘community workers’ ….
I’ve heard of people being employed as such. They start off with ‘home duties’, then appointments escort, and they are later expected to administer medications and treatments.
Friend of mine does this type of work and was employed without even a First Aid certificate !!
I received this further question as an email.
“I am an older paramedic, and love reading your posts. Just read the article on DNR and carers and your comments on their training with respect to certain legalities. I am wondering if you could discuss competency and nursing homes. I have on several occasions been required to transport nursing home residents who do not appear to have dementia and appear to have competency and capacity but are ‘being forced’ to go to hospital for treatment of an illness. They have communicated that they are old and happy to meet their maker and staff are unable to provide paperwork regarding enduring guardianship or similar that would allow me to transport the patient against their will. Of course I have only met this competent appearing patient for a brief time…how should this situation be handled in the event the ‘apparently competent’ patient refuses and needs force to transport to hospital.”
People are allowed to make decisions about their medical care; and they don’t lose that right just because they are old and living in care. Care is provided for their benefit and not for the administrative convenience of the institution. What follows is that if you, as a paramedic, think the person is competent and refusing treatment and transport, you should refuse to transport the person and raise the matter with the nursing and medical staff. If you need to use force, then it’s time to stop, involve other care professionals, and rethink the issue. Even an enduring guardian can’t override the patient’s competent decision. Enduring guardians are empowered to act when the person is unable to make their own decisions; the appointment of an enduring guardian does not remove the person’s own capacity.
Good you “older paramedic” for standing-up to the System of abuse that is ‘the Nurse Home Industry’ ( an industry whose ONLY purpose, is to make money ).
Even when the poor buggers are in pain, their ‘masters’ play down the severity, and they rarely get anything but Paracetamol.
( I could go on for hours about the systemic abuse in nursing homes ) ….
Hi, my father has dementia but he still recognises us and can eat and drink independently. He still enjoys life and spending time with family and relatives.
recently, he has problem with walking and seems to have a small stroke, and so, has been hospitalised. Doctor rang me today and said they will not resuscitate my father if his heart stops. I told him that I disagree and all the family want him to be back to life if anything happens. Doctor said because my father has dementia and Alzheimer’s Disease , in the next 6 to 12 months his life will be of low quality and deteriorate so they don’t think resuscitation is the best decision and so, regardless of what we want, they will not resuscitate my father if anything happens.
My question is: are doctors really allowed to do that to the patient who still has a lot of life left?
Without getting into specific details, medical treatment has to be preceded by the patient’s consent (Rogers v Whitaker) but the fact that a patient consents to, or wants treatment, does not mean that the medical profession has to provide it. Doctors are under no duty to provide ‘futile’ treatment (Airedale NHS Trust v Bland) and resources have to be allocated. There can of course be a debate about what is ‘futile’ but at the end of the day, doctors cannot be compelled to provide treatment that they think is not clinically indicated.
That there can be debate on the matter is however critical because the hospital’s doctors opinion is just that, an opinion. If the doctor’s at the hospital have taken a view and you disagree challenge it. Raise it with the hospital’s ethics committee. If your father’s regular treating doctors have a different view get them to discuss it with the hospital and its staff doctors. Make arrangements to get the patient out of that hospital asap.
I have been told that a DNR form is to be put on your refrigerator for the ambulance people to find is this correct
You just have to think about this to realise that it’s unlikely to work. Unless you have a cardiac arrest in the kitchen, paramedics are not going to be looking at the fridge. Even if they found the document could they be sure that it relates to you, they don’t know who lives there. I would suggest simply putting a DNR on your fridge is unlikely to help.
If you are executing a DNR order because you are at the end stage of a terminal illness speak to your doctor and contact your local ambulance service to see if they have procedures to register orders so that if an ambulance is dispatched to your address they are aware of the orders. Think about a medic- alert bracelet – or a tattoo – which could indicate where the formal order can be found. If there are carers involved make sure they know of the DNR and where to find it – which may be on the fridge but as I say simply putting it on the fridge, with nothing more, is unlikely to work because no-one’s going to find it.
A similar question on this.
In a Public Sector organisation, an employee tells their manager that they are DNR how does this then affect the employer in relation to first aiders or others providing CPR?
Does the employer need to sight verify and copy the DNR documentation?
Do they have to create a policy and procedure to cover DNRs within their work environment?
Does the employer need to provide specialist training for first aid officers / employees to deal with a DNR?
Telling the manager is like sharing any medical history – that the worker is diabetic, asthmatic, epileptic etc – they are no doubt telling their manager because they want the manager to know so that their needs can be accommodated. The manager should, in consultation with the worker, consider what that means and if it means telling the first aid staff that in the event of a cardiac emergency this person is not to be resuscitated then that seems reasonable.
Does the employer need to sight the DNR documentation? I’d want to and have a copy on file because people in positions come and go. And as an employer you want to communicate to the employee that you take their position seriously and want to give effect to it – so just as you want to record the phone numbers of next -of-kin and copies of asthma plans, having the DNR file on the staff file will help ensure it is respected and honoured.
Do they have to create a policy and procedure to cover DNRs within their work environment? I suppose it depends on the environment, its size, the risk, who the employee works with etc. Better yet is to have a policy to record and communicate to those that need-to-know relevant medical issues that may come up in the event of an emergency and this becomes one of them.
What that policy response looks like would be different if your emergency team is a group of employees who do a first aid course every three years and who, in the last decade, have never been called to provide first aid to anyone; compared to a workplace that has on-site dedicated health professionals (doctors, nurses and/or paramedics) who keep records on each employee, provide ongoing health monitoring and advice and treat many people for both work and non-work related illnesses and injuries each year.
My short answer is that an employee ‘tells their manager that they are DNR’ is telling them for a reason and that reason is probably that they want that DNR to be honoured, so the manager should speak to the employee about the best way to achieve that. The appropriate response will depend on the employee’s wishes, the size and nature of the workplace, the size and nature of the emergency response team, the emergency procedures. But the policy should be reflected in any policy related to recording, communicating and respecting any other relevant medical history information.