Lesson 4.5: End-of-Life Care, DNAR, and Advance Care Planning
End-of-life conversations are among the most demanding in medicine. PLAB 2 tests whether you can hold them with clarity, warmth, and the correct legal framework.
DNAR — Key Principles
A DNAR (Do Not Attempt Resuscitation) order is a clinical decision that CPR should not be attempted. It is made by the responsible clinician, not by the patient or their family.
- The decision must be based on clinical assessment: would CPR be successful? Would it serve the patient's best interests?
- The patient's wishes must be explored and respected if they have capacity.
- Family must be involved in discussions, but they cannot override the clinical decision.
- A DNAR does not mean withdrawal of all treatment. Comfort, pain relief, and all other care continue.
The Most Common Misconception
Relatives cannot demand that CPR be attempted if clinicians judge it to be futile or not in the patient's best interests. They also cannot demand a DNAR without clinical justification. Involve them in the discussion, ensure they feel heard, and explain what the decision does and does not mean.
If a relative says 'How dare you give up on my father': 'I can hear how much you love your father, and I want you to know we are absolutely not giving up on him. This decision means we focus all our efforts on keeping him comfortable and pain-free...'
Advance Care Planning
| Document | What It Is | Legal Status |
|---|---|---|
| Advance Decision to Refuse Treatment (ADRT) | A written, signed, and witnessed refusal of specific treatments in specific circumstances. | Legally binding if valid, must be followed even if the patient now lacks capacity. |
| Lasting Power of Attorney (LPA) for health and welfare | Grants a named attorney legal authority to make health decisions if capacity is lost. | Legally binding when registered with the Office of the Public Guardian. |
| Advance Statement | Records values, preferences, and wishes about care. | Not legally binding, but must be considered in any best-interests decision. |
| ReSPECT form | Recommended Summary Plan for Emergency Care and Treatment — records advance care planning discussions. | Widely used across NHS England. Records agreed clinical recommendations. |
Palliative Symptom Management
Palliative care is active, person-centred care focused on quality of life. When a patient or family is entering the terminal phase, use plain language, say 'dying', not 'transitioning' or 'passing', when clarity is needed.
| Symptom | Management Approach |
|---|---|
| Pain | Regular oral morphine titrated to effect; convert to subcutaneous infusion via syringe driver if unable to swallow. |
| Breathlessness | Low-dose oral morphine (evidence-based); upright positioning; fan directed at the face; anxiolytics if appropriate. |
| Nausea | Identify cause; haloperidol, levomepromazine, or cyclizine — via syringe driver if persistent. |
| Respiratory secretions | Hyoscine butylbromide via syringe driver; reposition; reassure family this does not cause distress to the patient. |
| Agitation / terminal restlessness | Midazolam via syringe driver; calm environment; address reversible causes (urinary retention, pain, fear). |
Always offer: hospice referral, chaplaincy or spiritual support, and bereavement support for the family.