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DNR orders imposed without consultation.

Medical staff have placed "do not resuscitate" (DNR) orders on thousands of patients in England without telling their families, a new audit suggests.

One-in-five families were not consulted where doctors decided not to revive their relative, a sample study by The Royal College of Physicians found.

A DNR order means medical staff will not attempt to bring the patient back to life if they stop breathing or their heart stops. The decision to use a DNR is taken by doctors but guidelines say medical staff must discuss it with relatives wherever possible.

The study of more than 9,000 dying patients in May 2015, found that, in 81% of cases where a DNR was in place, a senior doctor discussed the decision with a family, up from 72% in a 2013 audit.

However, in 16% of cases the decision was not discussed with relatives. In the other 4% of cases, records showed there were either no relatives or they could not be contacted.

Extrapolation from the 9,000-strong sample suggests thousands of people have had DNRs put in place without their family's knowledge.

Chairman of the audit, Prof Ahmedzai, said that often in the care of the dying, for example those suffering from terminal cancer or dementia, there was no medical benefit in attempting the resuscitation someone who was "slipping away peacefully."

However, he said that doctors and nurses needed to "do better" in terms of communicating with family members, as current practices were "not really acceptable."

The usual circumstances in which it is appropriate to issue a DNR include when it will not restart the heart or breathing, when there is no benefit to the patient and when the benefits are outweighed by the burdens

British Medical Association and Royal College of Nursing Guidelines say that DNR orders should be issued only after discussion with patients or their family.

In 16% of cases audited, the study also found there was no conversation with the patient themselves about the DNR order, and no record of why it had not been discussed.

Prof Ahmedzai said doctors needed to be more open with dying patients, particularly as half of those identified as likely to be dying did so within 24 hours.

An NHS England spokeswoman said there had been some improvement in the care provided but more could be done.