The Nursing Home Transfer with a Do-Not-Attempt-Resuscitation Form
You are called to a nursing home to transfer a 79-year-old man with advanced Parkinson's disease and recurrent aspiration pneumonia. He is drowsy but rousable, with a respiratory rate of 28, SpO2 88% on room air, and coarse crackles at both bases. The nursing staff hand you a photocopied 'do not attempt resuscitation' form dated two years ago, signed by the GP, with no patient or family signature. A daughter arrives and says 'do everything, he's a fighter'. The patient, when roused, says he is 'tired of all this' and 'doesn't want any fuss'. His advance preferences are not otherwise documented.
1. Analyse the status and weight of the DNAR form in this situation.
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The form must be interpreted carefully rather than obeyed or discarded reflexively.
- What it is: a copy of a GP-signed DNAR, two years old, with no patient or family signature. That is a clinically significant document but its provenance and currency are uncertain.
- What a DNAR does and does not do: it applies to cardiopulmonary resuscitation in the event of cardiac arrest. It does not, on its own, authorise withholding other treatments such as oxygen, antibiotics, or hospital assessment for a treatable deterioration. Confusing the two is a common and serious error.
- Currency: two years is a long time in advanced progressive disease. The form should be verified with the GP or the original record before being relied upon, if time allows.
- Patient's own voice: when roused he says he is 'tired of all this' and doesn't want 'fuss'. That is relevant but ambiguous - it may reflect fatigue, depression, or a considered wish. It should be explored, not interpreted for him.
- The daughter's view: she is not the decision-maker for a patient who may have capacity, but her concern should be acknowledged and she should be kept informed.
The tested judgement is that a DNAR is a specific instruction about CPR, not a general licence to downgrade care, and that its validity must be actively checked.
2. The patient's breathing deteriorates and he becomes unresponsive with a weak, slow pulse. Set out your decision-making and actions.
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This is now a peri-arrest situation and the DNAR question must be resolved in real time.
- Confirm the clinical state - responsiveness, breathing, pulse. If he is in cardiac arrest, the DNAR is directly engaged; if he is peri-arrest with a pulse, it is not yet engaged in the same way.
- Apply the DNAR only if verified. If you cannot verify it, and the patient is in arrest, the default is to begin resuscitation while attempts are made to confirm. Starting CPR is reversible; withholding it is not.
- If the DNAR is verified and applicable, honour it for CPR, but continue comfort-focused care, oxygen, positioning, suction, and symptom relief. A DNAR does not mean 'do nothing'.
- Communicate with the daughter honestly: explain what the form means, what you are and are not doing, and why. Do not promise interventions the form precludes.
- Document the clinical findings, the status of the DNAR, who was consulted, and the decisions made.
The tested judgement is acting safely under uncertainty: when the validity of a limitation-of-treatment document is unclear, err toward treatment and verification rather than toward withholding.
3. How would you handle the family disagreement if the patient had clearly lost capacity and no valid DNAR existed?
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- Establish the patient's best interests, using any known wishes, the views of those close to him, and clinical judgement about burden versus benefit.
- Treat the daughter's view as important evidence, not as a veto. Family members are consulted, not obeyed, when they are not the legal decision-maker.
- Seek the appropriate decision-making route - the treating team, the GP, and where necessary the formal best-interests process - rather than resolving it alone at the bedside.
- Continue comfort care and treat reversible problems while the decision is resolved.
- Document the disagreement and the reasoning clearly, because this is exactly the situation that is scrutinised afterwards.
The tested judgement is knowing the limits of your role: you contribute clinical information and act in the patient's interests, but you do not adjudicate family disputes unilaterally.