Death is the only certainty in life and most people will die in a hospital. For such an inevitability, few people consider how it will happen. Dying is a subject that carries great emotional weight, which might be why people are so reluctant to talk about it.

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A hospital death is usually preceded by an illness or a decline in health. Most doctors will recognise this and try to start an often unpleasant conversation about dying and death. I’ve initiated many of these and have seen plenty end in tears.

Do not attempt resuscitation (DNAR) forms are usually mentioned at some point. A DNAR form is completed to recognise that resuscitation will likely not be successful. CPR does not work most of the time. Most efforts I have witnessed have not restarted the heart. Only 10% of patients who undergo CPR will survive until discharge. The figure drops in those above 70. It is not the miraculous laying on of hands as depicted on TV.

Still, a one in 10 survival rate is better than nothing, right? In talking to patients, I sometimes hear a variant of this. Most people imagine a cleaner, clinical vision of this facet of healthcare – and are angry that we aren’t considering it. CPR is a brutal intervention rarely fully shown on programmes like Hospital or Junior Doctors. In reality, a team of professionals pounds on the patient’s chest (often breaking their ribs) as someone charges a defibrillator to try to shock them back to life. If it works there is a great risk of brain damage and other complications. The scene is noisy and chaotic. Given that most would prefer to die in the peace of their own home, that many finish their lives in this manner seems tragic.

With this in mind, it is hard to understand why doctors meet resistance when we suggest a DNAR. When I talk about not offering CPR, people have shouted at me or stormed out of the room. In one instance, a relative tracked down my surgical team to berate the consultant while we were seeing another patient. She was furious with us over the DNAR form. Maybe for her it cemented the idea that her mother was dying; a doctor suggesting that resuscitation in the future was a strong possibility perhaps implied that the end might be near.

A decision not to resuscitate is the last port of call. A common misconception over DNARs is that they are a sign of giving up on someone – and that once the form is completed, no further treatment will be provided. Yet all it signifies is that if the heart stops beating, we won’t restart it.

Facebook Twitter Pinterest ‘A reluctance to linger on the subject of death and the unrealistic glamorisation of TV are responsible for a great deal of misinformation.’ Photograph: Emilie Sandy/BBC

Good practice encourages the early and sensitive introduction of this concept, if CPR is an expected part of the dying process. It is important that we have this conversation early on if we think a decline is coming so that the patient is aware of the limits of care that we can provide. After all, a DNAR is a medical decision. We are stating from our body of clinical experience that a resuscitation effort is most likely to be futile or have overwhelmingly negative consequences.

To some, this decision might appear confusing if not properly explained. I have witnessed how unpleasant and ineffectual CPR can be; most of my patients and their next of kin have not. However, as nobody likes a prolonged chat about death, these vital yet awkward conversations might be glossed over.

Once while on call, I was asked by a nurse to speak to two brothers. She told me that they were cross and didn’t understand why their comatose father wouldn’t receive CPR. Though hearing this made my heart sink, I approached the bedside and sat with them. After hearing their worries, I asked about their dad, and what he thought about a good death. I highlighted what resuscitation meant, and said I was concerned that this wouldn’t be a nice way for their father to die. They weren’t angry; rather nobody had taken the time to explain the situation properly.

It is rare that families aren’t accepting of a DNAR once the circumstances surrounding it have been properly explained. A reluctance to linger on the subject of death and the unrealistic glamorisation of a handsome TV doctor in spotless scrubs, lightly tapping on a moribund patient’s chest and effortlessly resurrecting them, are responsible for a great deal of misinformation.

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There needs to be a greater national awareness and acceptance of death. We should be asking ourselves and our families how we want to die. Let’s all think about this and have the conversation while we are able.

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