Do not attempt resuscitation (DNAR) conversation is not only ICU responsibility: experience as an emergency physician in Qatar

Abstract

In a busy and hectic critical care setting, sometimes an ‘emergency’ Do Not Attempt Resuscitation (DNAR) conversation has to take place to prevent unnecessary ‘futile care’. Traditionally, this is the responsibility of Intensive Care Unit (ICU) doctors after discussion with family members, or by the primary care doctors after discussion with patients themselves prior to them becoming critically ill. Many critically ill patients with known ‘terminal illnesses’ brought to the Emergency Department (ED) in Qatar do not have a DNAR order. Increasingly, DNAR conversation is being undertaken by Emergency Physicians (EP), alongside ICU doctors. Often, these difficult conversations with family members occur in the ED prior to escalating resuscitation, if time permits. In Qatar, three physicians need to sign the DNAR order if they think it is clinically appropriate. Patients or their family members do not need to sign. However, hospital regulation allows it only after discussion with and agreement from them. Often, the DNAR order also includes the maximum intervention agreed. Some family members object the DNAR order, and insist on ‘full resuscitation’ and organ support, despite explanation of the poor prognosis, and the likelihood of non-curable deterioration. This review looks at the current practice, challenges and evolution of ‘emergency’ DNAR conversation in critically ill adult patients in Qatar.There are at least two different ‘opposing’ approaches to DNAR discussion with patients (and more often the case with family members of patients in critical care setting). The most often used is the patients’ choice approach1. In some society, patients discuss openly with their doctors about their condition fairly early on in the course of their illness. When they become critically ill, a similar discussion is undertaken with family members (or surrogates). A lot of emphasis is put on personal choices and preferences. Another approach, is a physician's driven DNAR recommendation when the clinical circumstance is appropriate2. This happens more commonly when patients present to hospital in late stages of their terminal illness (or with acute deterioration) without any DNAR order. In certain societies, DNAR is not generally discussed unless the condition is acute, life-threatening and the likelihood of a meaningful recovery becomes extremely small.Both approaches are probably the two ends of the same spectrum (see Diagram 1). Both involve risk-benefit discussion (and likelihood of success with good outcome) of cardiopulmonary resuscitation (CPR) in the event of deterioration and cardiac arrest. Having agreed on a DNAR status does not mean that the patient will get substandard care. Patients and families have to be reassured of this fact. Given the appropriate care, many patients with DNAR status recover from their acute illness episodes and are successfully discharged home after emergency hospitalization3. An appropriate DNAR order will guide the medical team (doctors and nurses) to avoid unnecessary ‘futile care’, and hopefully lead to ‘better’ personalized care for patients and their families4.