Monday, 29 October 2007

An experienced geriatrician speaks

The debate around empowering nurses to make DNAR decisions is certainly a hot one, I have obtained permission from an experienced consultant geriatrician to publish this short piece he wrote on the topic, the opinion of a geriatrician is particularly useful as they are in my opinion amongst the best at understanding the complex issues that surround DNAR decisions:

" "In general senior nurses are well qualified and well placed to make these decisions."

No they are not

As a geriatrician end of life decisions are my bread and butter. I work with mostly excellent nurses. But in my time as consultant I cannot think of a single senior nurse who would have been capable of making complex decisions like this in complex patients.

That is NOT a criticism of nurses. It is a compliment to doctors. On this issue my firm belief is this is something that almost no nurse could be reasonably asked or expected to do. And that's before we get to the issue of bearing responsibility for that decision.

Some things remain firmly in the domain of "a doctor's job". This is one of them. And before anyone cries "protectionism" all I would say is demanding the right to retain this responsibility as a doctor must surely be professionalism and nothing else."

The nail has been hammered home. It also seems that many nurses agree with this sentiment.


Elaine said...

When I was a Senior Staff Nurse in a Care of the Elderly Acute Medicine ward all those years ago, decisions such as those were taken by the multi disciplinary team caring for the patient (including family>) These decisions were then recorded in the patient's notes and in the nursing kardex. It was therefore perfectly ok for the nurse to call it over in the light of the previous decision.

Dr Ray said...

The above says it all. I remember being very uncomfortable with DNR decisions being written down to be followed blindly when this started happening 20 years or so back. The situation can change very quickly and the decision needs to be made on the spot. The entry on the kardex may not have been critically reviewed for hours or days. Saying "the nurse in charge of the patient is on her break and I have just come on duty" is not what I want to hear when a patient keels over-perhaps due to choking on a grape. Even a patient with terminal cancer does not deserve to choke on a grape. The other problem is as Garth has pointed out. A DNR notice on a patient seems to mean "not worth treating" and this decision is not for a nurse to make.

Garth Marenghi said...

an MDT is completely dysfunctional without a leader, and this leader is a senior doctor

without having someone in charge who has the expertise and experience, the team would not function

it should remain a doctor's decision in consultation with the team