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DNR: Often misunderstood, seldom a laughing matter

The first sentence of A Piece of Monologue (1977-79) by Samuel Beckett begins: “Birth was the death of him.” In Beckett’s case, both events were separated by 83 years; in my father’s, 90 years. Hospitalised, and with death approaching, the old boy — his mind strong, his heart weak, his wish to die resolute — retained his keen sense of humour. For example, he once regretted aloud that we’d never really discussed the topic of “youth in Asia”, as he put it, chuckling at my embarrassment but telling me not to worry: We were in Sunderland, after all, not Switzerland, which meant that the Grim Reaper couldn’t be hurried into any rash plying of the scythe.

“At least,” he said, “I’ve got a DNR [‘do not resuscitate’ order].” It almost sounded, I told him, laughing, as if it belonged with some of the medals he had amassed during the Second World War and he nodded, summoning a smile. A few days later, the medics complied with his DNR instruction… and the old boy died of heart failure.

But DNRs are seldom a laughing matter. For example, as a piece by Mary Carolan in The Irish Times (6 April 2017) makes clear, “a mother who is opposing the HSE’s application for ‘do not resuscitate’ orders for her severely brain-injured son has told the High Court she and her husband love their son and want him to live but not to ‘suffer’.”

I will not comment on this case, but the sentence quoted above brings to mind what Venneman et al noted in the Journal of Medical Ethics (2008, 34: 2−6) on the role of semantics in relation to DNR orders, with the title of their piece encapsulating the tension between two ways of considering the same issue: “‘Allow natural death” versus “do not resuscitate”: Three words that can change a life.’ Venneman et al suggest that “family members often misunderstand a DNR order as giving permission to terminate a loved one’s life, leading to conflict and often resulting in unnecessary suffering by the patient.” They could have a point. After all, ‘allowing a natural death’ (AND) might seem less emotive than DNR, at least to patients and their families. Health professionals, however, might consider AND to be freighted with more ambiguity than DNR. 

Yet quibbling about the relative merits of AND and DNR is perhaps getting a bit ahead of ourselves, given the findings of a recent Irish study, namely that “a substantial proportion of hospital doctors surveyed demonstrated an incomplete understanding of DNRs and their clinical operation”. Thus, O’Reilly et al reported on doctors’ attitudes towards the introduction and clinical operation of DNRs in Ireland in the Irish Journal of Medical Science (online 16 May 2017). Their cross-sectional, questionnaire-based survey of 103 doctors at Cork teaching hospitals found that 35 per cent “of all doctors surveyed demonstrated an incorrect understanding of a DNR” and although around 46 per cent of all doctors considered themselves sufficiently clinically knowledgeable to draft a DNR, almost half of this group selected the wrong definition of a DNR from three separate options. So there is clearly a need for domestic guidelines on DNRs to be introduced, a view endorsed by 93.2 per cent of the doctors surveyed.

In the UK, when Mockford et al reviewed ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders in the journal Resuscitation (2015, 88: 99−113) they observed: “Several recent high-profile cases in the media highlight evidence of inconsistency and poor implementation across National Health Service (NHS) Trusts in the United Kingdom. A review of current policy and practice is therefore required.”

My dad was fortunate to be mentally competent until the end and he was able to make clear his intentions in relation to a DNR order, but what about the challenge for physicians of determining the best interests of those patients without a voice for whatever reason? This was addressed by Armstrong et al, who considered Life and death decisions for incompetent patients: Determining best interests — the Irish perspective in Acta Paediatrica (2011, 100: 519−523). In a survey of fourth-year medical students, consultants and trainees in neonatology, paediatrics and obstetrics, they were questioned on scenarios involving a two-month-old, a seven-year-old and an 80-year-old. The study concluded that “the best interest principle is applied differently, more so at the beginning of life”.

This seems a sensible approach. To attempt resuscitation on, say, a 90-year-old with heart failure or a terminally ill cancer patient is not only against the best interests of the patient, it inflicts an undignified death on them. The late Leonard Cohen observed in song that “we’re only passing through”, yet to many, death seems an outrage and life should be prolonged at all — including agonising, if need be — costs. A significant number of this group profess religious views, many of which coalesce around the notion that only a being named God can take a life. But religion is man-made and when the time comes, I’ll take my chances with a man-made DNR.

  1. Paul O Reilly on June 28, 2017 at 12:17 pm

    What a very informative article on an increasingly topical subject matter both here in Ireland and abroad. With an ageing population “End of Life” matters clearly trouble both healthcare professionals and families alike.

    Written with humour and great sensitivity in equal measure.

    Look forward to similar articles in the future.

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