Emergency Medicine and DNAR – by Dr. Krishna Prasad G

The practice of medicine revolves around the principle of ‘Primum Non Nocere’ or otherwise known as 'First, Do No Harm’.

The topic of death or end-of-life is always a difficult one. Anticipating death is not what doctors are trained to do but in reality - death or turning really sick is a fact of life and it’s the constant conviction to come into terms with it is the most challenging part.

Having said so, it was difficult, not to notice two recent publications in key journals. Those were:

1. Mathur R. ICMR Consensus Guidelines on ‘Do Not Attempt Resuscitation’. Indian J Med Res. 2020;151:303-10

2. Dawood M.

End of life care in the emergency department.

Emergency Medicine Journal. 2020;37:273-278.

To talk about the end of a spectrum, where we have to finally say goodbye or knowing that there is no hope is one way of looking at it. I see DNAR (Do Not Attempt Resuscitation) as a way for the patient to live the remaining life with dignity and quality.

ICMR expert committee has taken a bold step in this direction and I would really like to congratulate them on this.

But, I think this might be the way to see development as a mature society. This might pave the way to see humans spent the last days of his with dignity rather than suffering undue pain and emptiness.

From an emergency physician’s point of view in India, there needs to be a drastic change in the way we receive patients for resuscitation.

Mani RK had mentioned that the Do Not Attempt Resuscitation (DNAR) order was not a documented legal practice in India. It is a verbal communication between the clinician and the patient’s relative or caregiver. The autonomy of the patient also remains a weak concept. Even the right to live a dignified life or die a dignified death has not been extensively discussed. The law is silent or ambiguous on most issues related to end-of-life care. The financial status of the patient appears to be the deciding factor. In most cases health-care expenses are entirely borne either by the patient or by the patient’s relative. (Ref: Mani RK. Limitation of life support in the ICU: ethical issues relating to end of life care. Indian J Crit Care Med 2003; 7: 112-7.)

While I was training as an EM resident, I had heard multiple times, that DNAR hasn’t got legal approval in India and we are bound to resuscitate each and every sick patient who comes to the ED, irrespective of any criteria. In some cases, I would imagine that the patient’s condition was so poor that he/she wouldn’t benefit from aggressive resuscitative measures. Documentation always held higher importance in these cases. In one way, it looked like we were playing safe. On the other, it looked like there was nothing we could do to help it.

This is the reason that I believe the ‘ICMR Consensus Guidelines on ‘Do Not Attempt Resuscitation’ is a landmark step in the history of medicine in India and is a must-read for all EM doctors in India.

Full Link: http://www.ijmr.org.in/article.asp?issn=0971-5916;year=2020;volume=151;issue=4;spage=303;epage=310;aulast=Mathur

I guess this document has got legal value because there are prominent people from MoHFW and ICMR involved in it.

I would like to suggest the following steps to implement the DNAR protocol across all hospitals in India:

• This policy document only outlines the basic instructions in dealing with DNAR situation. It would be beneficial for every hospital to adapt it into the local language also.
• A copy of the DNAR form should be given to the relative/patient and one copy should be kept in the hospital record and should be readily available. In some instances, when a sick patient with frailty and poor physiological reserve is brought to ED from a care home, it is prudential to know the DNAR status as soon as possible before instituting resuscitative measures.
• This form of intervention is entirely different from the usual academics. Therefore simulation based training for how to talk to a patient or relative regarding DNAR is very critical. Emergency physicians have a role to play here since most of the patients first point of contact with the hospital is the emergency department.
• A descriptive patient information sheet translated into multiple languages is also a need of the hour regarding DNAR.
• Medical training should encourage communication skills and the topic of DNAR itself is a fine example.
• Sometimes, a DNAR from need to be signed in the ED and then counter-signed/verified by the admitting specialist/consultant later. This needs to be incorporated also.

The next step is to focus on end of life care and I hope we will have a consensus soon.

About the author: Dr. Krishna Prasad G (MBBS, DNB(EM), MRCEM, MNAMS) currently works as a Senior Clinical Fellow at Luton and Dunstable University Hospital, United Kingdom. He can be reached at Krishna.Pillai@ldh.nhs.uk.