DNAR decisions in Pakistan, Middle East and UK: An emergency physician's perspective

Abstract

Although resuscitation aims to preserve life and restore health, it is sometimes at the expense of increased suffering and disability to the receiving patient. In this situation, the treating physicians often end up in the dilemma of whether resuscitation is appropriate for the patient and have discussions with the patient and/or family. This may lead to a decision to “Do Not Attempt Resuscitation” (DNAR). In western societies, the patients have an option to opt out of Cardiopulmonary Resuscitation (CPR) if they are in the situation, and at times, the medical team can make a clinical decision when the efforts are deemed futile. This is supported in the legislation of those countries, and as an example, the UK law states, There is no obligation to give treatment that is futile or burdensome.1 As the preservation of life in Muslim countries is of paramount importance due to religious reasons as well as cultures and traditions, a similar blanket approach to DNAR in Muslim countries is rarely seen. One of the earliest Fatwa (Islamic law) on this topic by Shaykh ‘Abd al-‘Azeez ibn ‘Abd-Allaah ibn Baaz and Shaykh ‘Abd al-Razzaaq ‘Afeefi in the year 1986, states “if reviving the heart and lungs is of no benefit and not appropriate because of a certain situation, according to the opinion of three trustworthy specialist doctors, then there is no need to use resuscitation equipment, and no attention should be paid to the opinions of the patient’s next of kin concerning the use of resuscitation equipment or otherwise, because this is not their specialty.” 2 This has led to physicians in Saudi Arabia being empowered to make DNAR decisions for their terminal patients and allow dignified death. The lack of similar legislation in Pakistan often places physicians in the unenviable situation of having to explain to patients and their families why CPR would be futile, and, in the absence of consensus, having to provide expensive, futile treatment, at the expense of the family, and other patients who may benefit from the resources used up. When possible, these discussions should be had by the treating speciality and the patient/families, but emergency physicians often find themselves in the awkward and undesirable situation of initiating these difficult conversations. The area to discuss and investigate here is about the ethical, religious, and legal implications of such a decision, and how an emergency physician can continue to act in the patient’s best interest while keeping themselves safe.