'Do Everything': DNACPR in Advanced Dementia
Mrs Cheung, 88, has advanced Alzheimer's disease, is bed-bound, doubly incontinent, and has had three admissions with aspiration pneumonia in six months. She lives in a residential care home and has a longstanding swallowing problem. She has no written advance directive. She is now admitted with another aspiration pneumonia; she is drowsy, her respiratory rate is 28, and her SpO2 is 88% on air. Chest X-ray shows right lower lobe consolidation. The team thinks she may need high-flow oxygen and possibly intensive care. Her son, an accountant, insists, 'My mother is a fighter; do everything, including CPR and ICU.' Her daughter, a nurse, says, 'She would not want that; she told me she never wanted to be a burden.' The son threatens to complain. A junior doctor asks you to sign a DNACPR order.
1. How do you approach the decision about CPR and escalation of treatment?
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First, establish whether Mrs Cheung has capacity for this decision; with advanced dementia and drowsiness, she probably does not, but capacity must be assessed rather than assumed. If she lacks capacity, decide in her best interests. Consider the likely outcome of CPR in a frail, bed-bound woman with advanced dementia and recurrent aspiration pneumonia: the chance of survival to discharge is very low, and the burdens of rib fractures, prolonged ICU stay, and loss of dignity are high. A DNACPR order is not a decision to withhold all treatment; she should still receive oxygen, antibiotics, fluids, suction, analgesia, and comfort care. Discuss with the family what 'do everything' means to them, and explain that CPR is a treatment like any other and may be inappropriate if it cannot achieve the intended benefit. A time-limited trial of ward-based treatment may be reasonable. Record the reasoning, and seek a senior clinician's opinion before signing the order.
2. How do you manage the conflict between the son and the daughter?
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Neither child has legal authority to consent for their mother, but both should be heard. Explore why the son says 'do everything' - guilt, fear of losing her, religious beliefs, or a misunderstanding of what CPR involves. Explore the daughter's account of what her mother said, when, and in what context. Explain that the decision is not a vote between siblings and that the team must act in Mrs Cheung's best interests. Hold a family meeting with a senior doctor and, if appropriate, a nurse or social worker; use clear language and avoid technical jargon. Explain that a DNACPR order does not mean abandoning her, and that she will still receive treatment for the pneumonia. Document the discussion. If disagreement persists, seek a second consultant opinion and clinical ethics committee advice. A complaint is not a reason to provide futile treatment, but it is a reason to communicate better and to show that the family has been heard.
3. What if the son continues to demand CPR regardless of the medical opinion?
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You are not obliged to provide treatment that is clinically futile or contrary to the patient's best interests. CPR in this situation is very unlikely to succeed and may cause distress and harm. Continue to explain this compassionately, and offer to involve a senior clinician, an independent second opinion, or the ethics committee. If the son remains dissatisfied, he can use the hospital complaints process; this should not change the clinical decision. Ensure that Mrs Cheung is comfortable, that symptoms are controlled, and that the family is supported. Document the DNACPR decision, the reasons, who was consulted, and the fact that the son disagreed. If there is a genuine dispute about what is in her best interests, and time allows, seek advice from the Guardianship Board or legal team, but do not delay comfort care. The goal is a dignified death, not a contested technical intervention.