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Cardiopulmonary resuscitation: who makes the decision?

Queen Elizabeth Hospital, Birmingham B15 2TH Selly Oak Hospital, Birmingham B29 6JD University of Birmingham Medical School, Birmingham B15 2TT Correspondence to: Dr Heath.

Recent guidelines suggested that cardiopulmonary resuscitation should not be given (a) when a patient competent to give informed consent does not wish to have it, (b) when a patient is not competent to give consent and resuscitation is considered to be against his or her best interests, or (c) when resuscitation would probably not be successful.¹ Attempts are made, however, to resuscitate patients with little prospect of recovery,*RF 2-4* and few doctors in Britain ascertain whether a patient wishes to be resuscitated.

We explored doctors' views on resuscitation and determined if it was possible to ask patients whether they would wish to be resuscitated.

Methods

and results

A questionnaire was sent to 80 hospital doctors to establish who took part in decisions on which patients to resuscitate and to ascertain which patients would be resuscitated. Before being discharged from a general medical ward 50 consecutive patients were asked who should decide if patients should be resuscitated and whether they would have wanted to be resuscitated if they had collapsed during their admission. A further 50 consecutive general medical inpatients were asked within 24 hours of admission whether they wished to be resuscitated if they collapsed during their admission. In both groups of patients, the patients' wishes were compared with the decisions of the medical team.

Only one of the 34 doctors who returned the questionnaire thought that patients should be consulted routinely on the decision to resuscitate; the remaining 33 doctors thought that patients should never or only rarely take part in the decision. In practice no doctors discussed resuscitation with patients, although two spoke to relatives. While junior staff who returned the questionnaire would resuscitate all healthy people irrespective of age, seven of the 24 senior staff would not resuscitate healthy patients aged over 70. Although the doctors' reluctance to resuscitate patients increased with increasing severity of illness, a third of the doctors would attempt to resuscitate patients with incurable malignancy.

The table shows the patients' responses. All patients thought that resuscitation should be discussed with them, and only one was emotional during the interview. Overall, 59 wished to take part in the decision, and many thought that the decision to resuscitate should be theirs alone. A substantially greater proportion of patients (especially women) over 60 than 60 or under did not want to be resuscitated, even though few had malignant disease or were expected to die soon. In 65 cases the patients and doctors agreed about resuscitation. In 27 cases, however, the doctors favoured resuscitation while the patients did not; disagreement between doctors and patients was particularly common when the patients were women over 60 (in 21 of 47 cases the women did not want resuscitation while the doctors did).

Results of survey of 100 general medical inpatients about cardiopulmonary
resuscitation. Values are numbers (percentages) of patients unless stated
otherwise
---------------------------------------------------------------------------------------------------------------
                                                    Before discharge            Within 24 hours of admission
                                            -------------------------------------------------------------------
                                                  Men             Women            Men              Women
                                                 (n=24)          (n=26)           (n=20)           (n=30)
---------------------------------------------------------------------------------------------------------------
Average (range) age (years)                      61 (25-84)      66 (20-85)       63 (29-83)       71 (51-85)
Patients wishing to take part in decision on
  resuscitation                                  18 (75)         17 (65)          12 (60)          12 (40)
Age of patients not wanting to be
  resuscitated (years)
    <=60                                       1/10 (10)        1/5 (20)         1/6 (17)         0/4 (0)
     >60                                       6/14 (43)       13/31 (62)       4/14 (29)       17/26 (65)
---------------------------------------------------------------------------------------------------------------
 Differences between two groups of patients and between men and women were not significant.

Comment

Despite the poor response rate to the questionnaire (43%) our results clearly show that few doctors seek patients' views when deciding whether to resuscitate. Furthermore, many doctors would attempt to resuscitate patients with little or no prospect of recovery.

Doctors generally believe that it would distress patients to discuss resuscitation.⁴ In our survey, however, all patients thought that it was appropriate for doctors to discuss it with them, and most wanted to take part in the decision. Indeed, the wishes of many of the older patients conflicted with the doctors' decisions. If doctors are to satisfy the guidelines for withholding resuscitation they will have to make important changes in the way they practise.

1. Doyal L, Wilsher D. Withholding cardiopulmonary resuscitation; proposals for formal guidelines. BMJ 1993;306:1593-6.
2. O'Keefe S, Redahart C, Keane P, Daly K. Age and other determinants of survival after in-hospital cardiopulmonary resuscitation. Q J Med 1991;296:1005-10.
3. Smith EM, Hastie IR. Resuscitation status of the elderly. J R Coll Physicians Lond 1992;26:377-9. [Medline]
4. Schade SG, Muslin H. Do not resuscitate decision: discussions with patients. J Med Ethics 1989;15:186-90. [Abstract/Free Full Text]

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Elderly patients and resuscitation: Advanced age is not a factor

N P Thompson, G H Jenner, A Wagg, M Kinirons, K Stewart, B Yip, and I M Lenox
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