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You are a foundation doctor on a geriatric ward, looking after Mr Klozine, a 92-year-old man with dementia, AF, COPD. He has been admitted to hospital with shortness of breath and a cough with green sputum. A chest X Ray is undertaken, and an infective exacerbation is confirmed. He is subsequently commenced on antibiotics, but continues to deteriorate. The ward consultant is concerned that it if Mr Klozine’s heart were to stop, it would not be appropriate for resuscitation to take place because there would be no realistic chance of success. Si is currently too unwell to discuss the matter. Si’s son has come to the ward to visit.

Please discuss this matter with Mr Klozine’s son. Take care to elicit Mr Klozine’s son’s concerns and come to a shared decision.

You are Si’s son, Paul who has come in to visit your dad. You’re very concerned that he is deteriorating and this chest infection has particularly knocked him. You don’t like to see him with the oxygen mask on and looking so frail. Your mother died in a hospice from breast cancer 8 years ago. You are married with no children but have two dogs, Ant and Dec.

Your dad lives in a care home but you visit most days. You understand he has had multiple illnesses and are aware that he is not a well man.

If the doctor mentions Lasting Power of Attorney, Advance Decision to Refuse Treatment or any other planning documents, you have heard the names but haven’t put any in place for your dad.

When the DNACPR is mentioned, you feel shocked as you didn’t think he was dying. You wonder if this means that he only has days left. You are unsure if his current medications will continue and if he will be allowed to go back to the care home. You wonder what would happen if he had a heart attack- would he get any treatment? Would it hurt without the CPR? Would it hurt with the CPR? You wonder what will happen if he gets another pneumonia or cancer.

You will be reassured if the student discusses your concerns with you in depth and provides you with appropriate answers to your questions.

The candidate should establish rapport with the relative and ensure they are up to date with Si’s clinical condition. They should present the DNACPR very sensitively as a medical decision that has been made because the treatment is so unlikely to be successful. They should emphasise that this is only relevant if Si has a cardiorespiratory arrest, and current treatment will continue. It may be useful to highlight that Si isn’t immediately dying, but now is a sensible time to make sure decisions have been made incase he deteriorates now or in future. The student should reinforce that whilst it is a medical decision, teams like to have family input, and that if family are completely against DNACPR, they will not proceed with the form.

Points for discussion may include: - Required documentation involved with DNACPR - Where the DNACPR document should be kept - The success rate of CPR