Raksha02
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Hey! I'm a premed prepping for interviews, and I had a doubt. If a doctor decides to make a DNACPR decision for a patient, but the patient objects to it, but the doctor thinks CPR is not clinically beneficial for the patient, what do they do?
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Emily_B
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(Original post by Raksha02)
Hey! I'm a premed prepping for interviews, and I had a doubt. If a doctor decides to make a DNACPR decision for a patient, but the patient objects to it, but the doctor thinks CPR is not clinically beneficial for the patient, what do they do?
Then they don't put a DNR in place. Still do CPR if the patient has a cardiac arrest.
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Democracy
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(Original post by Raksha02)
Hey! I'm a premed prepping for interviews, and I had a doubt. If a doctor decides to make a DNACPR decision for a patient, but the patient objects to it, but the doctor thinks CPR is not clinically beneficial for the patient, what do they do?
There is a general principle of medical consent whereby patients (with capacity) can decline whatever interventions they please. You cannot, however, demand medical intervention if it is judged to be inappropriate.

It is good practice to discuss DNACPR decisions with the patient. If the likelihood of successful CPR is judged to be very low then this should be sensitively explained. In reality, most resuscitations are unsuccessful and it's unusual for a successful resuscitation to occur without any traumatic or neurological sequelae. It's important to explain that it's not like TV as there are a lot of misconceptions in the general public's hive mind. It's also important to explain that the decision may be reconsidered depending on the patient's condition and that it doesn't apply to all forms of resuscitation - only CPR.

From what I've seen, when all of this is fully explained to patients and they (and family members) are given the chance to ask questions, there isn't any further confusion or disagreement. Patients often seem quite gratified once they've been presented with all the facts and understood that it's not something that will help them in the last moments of their life.

If there continues to be disagreement, then a second opinion should be sought.

More info here:

https://www.nhsfife.org/nhs/index.cf...81355468F#S4Q5

https://www.gmc-uk.org/ethical-guida...uscitation-cpr

https://www.alzheimers.org.uk/get-su...ot-resuscitate

https://www.theguardian.com/healthca...t-patients-die

(Original post by Emily_B)
Then they don't put a DNR in place. Still do CPR if the patient has a cardiac arrest.
You cannot demand medical interventions if they are deemed to be inappropriate. You can refuse medical advice however (if you have capacity).
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Emily_B
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(Original post by Democracy)
You cannot demand medical interventions if they are deemed to be inappropriate. You can refuse medical advice however (if you have capacity).
I've spent a lot of time with patients and their families while DNACPR decisions have been discussed. 99% of them have taken the medical advice and agreed with the DNR decision. I have also, however, witnessed the discussions be had with patients with full capacity where the patient decision has been that they want full intervention, including medically deemed inappropriate CPR, and no way were they going to let the medical team they were under put a DNACPR decision & relevant forms in place. They remained for full code; their decision re their care.
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Democracy
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(Original post by Emily_B)
I've spent a lot of time with patients and their families while DNACPR decisions have been discussed. 99% of them have taken the medical advice and agreed with the DNR decision. I have also, however, witnessed the discussions be had with patients with full capacity where the patient decision has been that they want full intervention, including medically deemed inappropriate CPR, and no way were they going to let the medical team they were under put a DNACPR decision & relevant forms in place.

At the end of the day it's the decision of the medical team, though good practice is to involve the patient at all times. The same way you cannot walk into hospital and insist on receiving an endoscopy or an MR scan or any other medical intervention, you cannot insist that people jump up and down on your chest, shock you, and put tubes down your airway if it is not medically appropriate to do so.

It's not easy to comment on anecdotes. I don't know whether some teams might reverse their decision based on strong patient objections or go along with something they initially deemed as inappropriate. But for the purposes of a medical school interview, I think what I have written is the answer to the OP's question (and the sources agree):

"The fact that a treating clinician considers that CPR will not work means that the patient cannot require him or her to provide it. It does not, however, mean that the patient is not entitled to know that the clinical decision has been taken. Nor does it mean that the patient should not be given the opportunity to seek a second opinion"

...

"Following discussions, the decision whether to issue a DNACPR order ultimately lies with the treating clinician. However, if the patient or others disagree with the decision, a second opinion should be sought"

https://www.bmj.com/bmj/section-pdf/...lysis.full.pdf
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Raksha02
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Thank you both very much for the replies! I have a lot more clarity on this topic now
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nexttime
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It is a medical decision and medically and legally the patient has no right to demand a treatment on the NHS that they don't need.

However, complaints are very bureaucratic and sometimes unpleasant and often the consultant in charge would rather let the juniors do 5 minutes of completely pointless CPR then give up, rather than taking on that argument. Not the 'proper' thing to do, but true.
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Raksha02
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(Original post by nexttime)
It is a medical decision and medically and legally the patient has no right to demand a treatment on the NHS that they don't need.

However, complaints are very bureaucratic and sometimes unpleasant and often the consultant in charge would rather let the juniors do 5 minutes of completely pointless CPR then give up, rather than taking on that argument. Not the 'proper' thing to do, but true.
Oh I see, but in interviews it is better to say the proper thing to do right?

Thank you for the response!
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(Original post by Raksha02)
Oh I see, but in interviews it is better to say the proper thing to do right?

Thank you for the response!
In a med school interview I'd say that there is a lot of misinformation about CPR among the public, and that the patient/family may not realise the medical implications of their current treatment or a DNR. In the vast majority of circumstances a sensible discussion between both groups results in understanding and an agreement. If that did not work I would escalate to a registrar/consultant.

If I was interviewing to be a consultant, I would say the above but then that ultimately I have a duty to protect my patients including from very harmful, very painful, completely unnecessary procedures like unneeded CPR. In a very difficult circumstance, like a young patient with terminal cancer and a distressed family, I would seek advice from a fellow consultant, but ultimately I do need to do the proper thing and protect my patients.
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GANFYD
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I have DNACPR discussions a lot and in a different situation to hospital doctors, as my patients are generally not acutely unwell when we start the conversation.
This is not for an interview question reply so much as to stimulate thought (and the above point would be a good one to make at interview; GPs have an ongoing relationship, time, a relationship with relatives, MDT support, etc that hospital doctors often lack).
I discuss the false impressions people have about CPR (eg Holby City, shock them and they get up and nip off to Costa for a coffee). I discuss success rates (or lack of them) and negative sequelae of "successful" CPR. I tell patients we are not talking about "treatment for a heart attack" - a reasonably fit 85 year old almost certainly warrants treatment for a heart attack in terms of stents etc, and I make the distinction between a heart attack and a cardiac arrest. I discuss what actually happens at CPR and how undignified it is and particularly how distressing it is for relatives. I discuss the post-CPR repercussions - a deceased person will most likely end up in A&E, with nobody able to issue a death certificate, the coroner involved and possibly a post mortem, whereas a DNACPR allows the GP to be called, the body to remain where it is or go to a funeral directors (if an expected death), relatives to spend some time with the recently deceased person and paperwork to be completed by the people who likely know the patient best. The thing that usually has the most impact is when I tell them that if their heart stops beating at X age with Y health problems, it is not because there is some reversible condition that CPR will magically terminate, it is because it is their time and I wouldn't be having this conversation with them if I didn't think it appropriate.
Most people who are old or sick are aware of the possibility of their own demise and happy for the opportunity to discuss and think about how things may actually happen. We include it as part of a Care Plan where we discuss things like ADRT, Lasting Power of Attorney, goals they want to achieve health-wise in the next year, people we can discuss their health with, etc etc. I never rush it, try and make sure they have support, give written info and allow them time to think about it if unsure. I also remind them they can change their mind or we can revisit the situation if their health changes. I have only ever had 1 patient who wanted CPR to be tried, despite the information given, where I thought it was inappropriate. I have also had one who was made to come back and discuss it again by his family as they had "read about Drs that just decide they are not going to resuscitate somebody without discussing it" and the patient said to me "I said to them - I have just told you, it was discussed with me at great length and now I'm discussing with you, like the Dr suggested!"
We followed his wishes and his care plan was drawn up acoordingly.
What is also an issue is that we try (where possible) to send community CPRs in if we admit a patient, but usually don't get them back. We also frequently get a discharge summary stating "DNACPR put in place" when the patient has had one for years in the community. So communication is once again shown to be the key part of DNACPR discussions!
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Raksha02
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Thank you all for the replies! I understand that this is much more than the right and wrong things to say and do, and that there are case specific complexities.
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