A DNR is applied to a patient if in the course of their hospital stay/treatment their heart stops beating and medical staff are not then supposed to attempt to restart the heart. Now obviously this is a difficult area as it means making decisions about whether there is any point in saving a life.
Circumstances where a DNR might be applied
- If the patient expressly wishes it in a living will or advanced directive. - not the same as euthanasia
- If there is an indication that resuscitation will cause more suffering
- If there is a strong chance CPR will not work
- It is not in the patients best interest.
Who should medical staff talk to?
Ideally the patient, however, if the patient lacks capacity the medical staff should seek guidance from their safeguarding officer and should also take into account the view of carers and family. Although they don't have to follow the wishes of relatives or carers, there should be clear signs that they've both sought and that should also be noted. Every hospital should have a clear policy available for all to read.
Having said all this though, the final word however does rest with the medical staff (according to the GMC) GMC Guidance.
Now all of this is very interesting, but two things stand out for me, the first is the concept of best interest and the second is concept of undue suffering.
Both of those sound fairly straightforward but they aren't concrete decisions, they're value based decisions which are based on some fairly abstract concepts one of which is the value of human life.
We would all like to think we view human life as having value, but realistically some lives have more value than others and this is where this decision to DNR a man with Down Syndrome who also has Dementia starts to take on a different slant.
Ask yourself the following question about who's life holds greater value.
- A toddler
- A newborn baby
- A 98 year old man
- A 21 year old soldier
- A 18 year old university student on his way to first day at Cambridge to study Medicine on a scholarship
- A terrorist
- A 9 boy with Down Syndrome
- A 25 year old Football star
- A 45 year old black man in Sierra Leone
- Your next door neighbour's teenage son
- A dead puppy
You'd be tempted to say that people all hold equal value as human beings, however, the reality is that if you hear about any one of these people listed above dying, you'd have a variety of emotional responses based on whether you observed it, whether you knew that person, whether you've experienced something similar in your own life, how the death came about and perhaps most important of all, your own personal circumstances and what you might deal with on a regular basis.
Empathy is two way
If during your daily working life you cope with and deal with death and suffering pretty regularly this means that you have to adjust your viewpoint in order to cope emotionally. If, as a doctor or medical staff you became emotionally distraught every time a patient dies, then you'd be a pretty useless member of staff and probably not last very long working in clinical medicine.
If we expect Doctors and nurses to have empathy, then we must also expect this empathy to work in the opposite direction. Keep in mind that often a Dr or Nurse will be in their late 20's early 30's, be academically bright and excelled throughout their careers. They have normal(ish) lives with families, friends, mortgages etc. The biggest difference though is that a significant proportion of the people they come into contact with (depending on clinical circumstances) may end up dead. I don't mean they all die, but, realistically very few other professions have the same ratio of meeting a person who then ends ups dead shortly thereafter. This must have an impact on how you view the world and the population within it.
Different Values
The reality for all of though is we place different values on every one's life. Take that list again and tell me which one would upset you most if you heard about it on the news? Or, you witnessed it? The fact of the matter is, that in society currently, the man with dementia who dies is not news, the man with Down Syndrome who dies is not news.
They are not deemed to be worthy of our sympathy because for most people the sympathy is not there. This does not mean that to their families, their friends and to those that know them their life has any less value.
There must be a better way for a family to find out about a DNR than finding it in the notes and discovering the reasons are learning disability and Down Syndrome.
Rather strangely in the UK, often the the 11th item on that list would encourage the most sympathy and emotional response.
All Life Has Value
All life has value and when making decisions that impact on that value, we should do it with Empathy. Stand in the shoes of that person, that person's family and then we might not have such a shocking story again.
It's about changing attitudes of course, but for me it's about changing the view of the value of the life of someone with Down Syndrome (or other learning disabilities) and the value of life of someone with Dementia.
