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The Royal Marsden School

How to have ‘that’ conversation

Talking to a patient and their family about a Do Not Resuscitate (DNR) order is never easy, but you can learn to do it with compassion

Clear communication with patients is crucial when it comes to healthcare, but The Care Quality Commission (CQC) found that 50% of complaints to organisations relate to communication – with the majority related to end-of-life care.

Discussing a Do Not Resuscitate (DNR) order with patients and families is an important part of any conversation about their treatment, but there’s a right way and a wrong way to go about it.

Lloyd Allen, Advanced Communication Skills lecturer practitioner at The Royal Marsden School, says, ‘This conversation often goes wrong if you go through it with the patient in a kind of tick-box process. Many healthcare professionals say, “I have to complete this form with you. When it comes to DNR, what are your wishes?” It’s a very unhelpful approach.’

This ‘tick-box ’discussion can make patients feel much more distressed and scared than they need to. ‘It can leave them feeling like someone’s just come in and written them off,’ warns Lloyd.

So you need to understand how to have this conversation sensitively.

Is there a right time?

It’s important to have a DNR discussion much sooner in the process – if it takes place near the end, you could be dealing with an emotional, exhausted patient and their family. ‘Ideally, they will bring it up,’ says Lloyd. ‘It shows they’ve given it a lot of thought, so encourage them to tell you their priorities.’

If you need to raise the subject of DNR, do it as part of a conversation about what their future care might look like. Lloyd says, ‘Find out what they understand about their condition, and give them time to reflect on what has happened to them and what doctors have told them.’ This will help them acknowledge and accept their declining health. ‘They might hope to get better but by having this honest conversation, a patient will be more able to think about their future care, and how DNR is part of that,’ adds Lloyd.

You can also make them aware that DNR is one way to ensure that any future care meets their ongoing needs. Lloyd says, ‘Ask them, “Have you given DNR any thought or consideration?” It’s most effective when patients feel they are involved in their own treatment.’

By having this honest conversation, a patient will be more able to think about their future care, and how DNR is part of that.

The realities of resuscitation

Your patient may not want to receive end-of-life care in a hospital, but would prefer to be at home, or in a hospice, with family and friends. When you include DNR in a conversation about their end-of-life care, you can make them aware of the benefits of having their wishes adhered to.

‘A DNR notifies other medical professionals that a patient does not want be rushed into hospital and put through the process of resuscitation,’ says Lloyd. ‘Everyone is aware that they would prefer to be somewhere calm and comforting, not in the middle of a chaotic emergency ward.’

Resuscitation itself is a difficult process; it can be very distressing, it may cause serious side effects and could stand very little chance of success if the patient has a terminal illness. ‘If you believe the patient should not be resuscitated, you need to explain why – calmly and with empathy,’ says Lloyd.

Don’t be scared of DNR

The key to discussing DNR is to ensure that the patient feels they are in control of their future care, rather than feeling as if their treatment is something that happens ‘to’ them.

Lloyd says, ‘If you can discuss their thoughts and wishes around end-of-life care then DNR makes a lot more sense as part of that whole conversation, not just a form that needs to be filled in.’

To learn more about dealing with challenging conversations, take a look at our Advanced Communication Skills Training course.