Do not attempt resuscitation (DNAR/DNR), a short thread.
There seems to be a lot of confusion about resuscitation and ‘DNR’ orders.
I’ll try to clear up some confusion.

What qualifies me to write about this? I’m an intensive care consultant who has managed 100s of attempted resuscitations, I’ve looked after 100s of patients after cardiac arrest in ICU, I lead a resus team. I’ve discussed resuscitation with 1000s of patients and families.

Resuscitation (or to be precise cardio-pulmonary resuscitation, CPR) is a treatment to restart the heart if it stops. It is invasive and unpleasant, often leading to broken ribs, brain damage and sometimes internal bleeding.

If a patient has a realistic chance of recovery, and they want to be resuscitated, the risks may balance the potential benefits. But there is a risk of major brain damage, even if the heart is restarted.

It is most effective when the patient’s heart stops because of an abnormal rhythm that we can stop with an electric shock (defibrillation). It's much less effective if the heart stops because the rest of the body is sick.

Patients who suffer cardiac arrest in hospital are much less likely to survive than those whose hearts stop outside hospital, 9 in 10 patients whose hearts stop in hospital due to their body being sick will not survive to 1 year.

Patients who have significant pre-existing conditions, who are already frail and elderly, are much less likely to have their hearts successfully restarted. Even if they do restart they are unlikely to get out of hospital.

If we do manage to restart the heart the patient almost invariably needs to come to ICU, another invasive and unpleasant intervention that is only worth doing if a patient has a realistic chance of recovery.

So when doctors say they advise against resuscitation, it is because we are advising against a futile and harmful treatment. One can no more demand CPR than one can demand chemotherapy for a chemotherapy-resistant cancer, and it is unethical to offer futile treatments.

Do Not Resuscitate means ‘do not attempt a futile treatment’, and often means ‘allow a peaceful and dignified death’. It does not mean ‘do not treat’, it does not mean ‘do not care’ it does not mean ‘abandon you alone’. It is not a plot to cull the elderly and frail.

It means ‘do not assault this patient when they are dying’, it means ‘first, do no harm’.

I’m not religious, but a wise mentor of mine once said ‘when God lays his hands on the patient, take yours off’. We will all die one day, I would like to die with dignity and peacefully and try to ensure the same for all my patients who are dying. That's why I write DNAR orders

COVID addendum - COVID mostly kills people because they can't get enough oxygen to their heart and brain. In these circumstances, CPR is often ineffective - especially if already receiving maximal supportive treatment.

This thread seems to have generated a lot of readers. I don’t have anything personal to promote, but please do consider filling in the Covid core outcomes study survey so we can make sure clinical trials address the needs of patients

https://sydneypublichealth.au1.qualtrics.com/jfe/form/SV_1AmgErWpIJVSAYd

And to add some data- survival with good neurological outcomes following cardiac arrest in patients with #COVID19 is very rare. To those who ask “how can you know” https://www.sciencedirect.com/science/article/pii/S0300957220301428