A lucid question at 02:40: truth-telling, family wishes and an undocumented DNACPR
Mr Chan, 78, has advanced Alzheimer's disease (MMSE 12/30) and was admitted three days ago with aspiration pneumonia. A chest CT performed after a fall shows a 4 cm lung mass with mediastinal lymphadenopathy and two liver lesions; the respiratory team documents 'probable metastatic malignancy, further tests pending'. His daughter, his main carer and next of kin, tells the ward team, 'Don't tell him anything - it would kill him.' At 02:40 Mr Chan is unusually alert, makes eye contact with the night nurse and asks clearly, 'Am I dying? What did the scan show?' In the notes there is a 'Not for CPR' form completed by the on-call doctor, with no record of discussion with the patient or family and no reason documented. The ward has no ethics consultation service overnight, and the nurse is the only registered nurse on the floor with a new graduate.
1. What should the nurse say and do in response to Mr Chan's question at 02:40? Set out the ethical and legal reasoning, including how the daughter's request should be handled.
Read the worked answer
Start from capacity, not from the diagnosis.
- Capacity is assessed functionally, for this particular decision, at this particular time: can he understand the information, retain it, weigh it and communicate a choice? An MMSE of 12/30 is a warning sign, not a verdict. He is orientated enough to ask a direct question, so the nurse must assess and document his understanding by asking him what he knows.
- Consider delirium. Hypoxia, sepsis, anticholinergic drugs and sleep deprivation can produce lucid windows. Check SpO2, temperature, glucose, pain, bladder distension and the drug chart, and treat reversible causes; this does not remove the duty to answer honestly now.
Do not lie and do not promise secrecy. Deception breaches dignity, autonomy and the professional code, and would leave him unable to plan. 'Therapeutic privilege' is narrow and cannot be invoked simply because the family is distressed.
Use a graded, patient-led response: 'You've asked me a serious question. Tell me what you've been told so far, and how much would you like to know tonight?' Then give truthful information at his pace - for example, 'The scan showed a serious abnormality in your lung and the team needs to talk to you properly in the morning.' Offer to have the doctor and his daughter present, and check what he has understood.
With the daughter: acknowledge her fear, explain that he has asked directly and that you cannot lie, but offer to agree the timing, setting and who is present for fuller disclosure.
2. What should the nurse do about the 'Not for CPR' form before the morning ward round?
Read the worked answer
Recognise what the form is. A DNACPR decision is a clinical treatment decision made by an appropriately senior doctor; the nurse does not make it, remove it or alter it. But the nurse is accountable for checking that it is valid and for escalating concerns.
Check the four things that make it defensible:
- Who signed it, and were they competent to make that decision?
- Is the clinical reason documented?
- Was the patient involved if he had capacity, or the family involved in a best-interests discussion if he did not?
- Is it dated, unambiguous and applicable to this admission?
Here, points 2–4 are missing, so the form is unsafe as it stands.
Escalate now, not at 08:00:
- Page the on-call medical officer and ask for a documented review, explaining precisely what is missing.
- Inform the nurse-in-charge or ward manager and, if no review is possible, the duty hospital administrator.
- Keep the form in the notes; do not remove it. If a cardiac arrest occurred before review, follow hospital policy and the existing order, and document the ambiguity.
- Record the time of your concerns, who you contacted and what was agreed.
- Complete an incident or risk report if local policy requires it; an undocumented, un discussed DNACPR order is a patient-safety event.
Also act on the patient's side of it: if Mr Chan has capacity, a DNACPR cannot simply be imposed on him, and his own view must be sought.
3. Write the nurse's documentation and handover plan, and explain how the daughter's request should be carried into the multidisciplinary team plan.
Read the worked answer
Documentation should be factual, time-stamped and non-judgemental. Record:
- 02:40 - patient alert, asked 'Am I dying? What did the scan show?'; what he said he already knew; what was said in reply and his response.
- The daughter's exact request and the nurse's response.
- The DNACPR form: found, contents, missing elements, who was paged, at what time, and the outcome.
- Any delirium screen and actions (observations, glucose, medication review).
Avoid opinions such as 'daughter in denial'; record behaviour and words instead.
Handover should flag three things: an unresolved disclosure question, an unresolved DNACPR validity question, and a family meeting that needs a senior doctor. Use SBAR so that the morning team cannot miss it.
Carry the family's wish into the plan without giving it a veto. Propose a documented plan agreed with Mr Chan: what he has been told, what he wants to be told, who should be present, and how much detail he wants. If he lacks capacity for that decision later, the team must act in his best interests, taking the daughter's views into account as one voice among others - not as the deciding one.
Advocacy is a continuing role. If the team's plan becomes 'tell her we won't tell him', the nurse should say plainly that this conflicts with the patient's right to information and ask for a documented rationale.