Editorials
Do not resuscitate decisions: flogging dead horses or a dignified death?
Resuscitation should not be withheld from elderly people without discussion
An elderly woman died in hospital and her family,
investigating her care, found "NFR" (not for resuscitation) on her
notes. There had been no discussion about this with either her or them. An independent review upheld the family's complaints and noted, "It
was hard to avoid the conclusion that the treatment plan
. . . was to do little more than allow the patient's
life to ebb away." This is just one of a dossier of over 50 case
histories assembled by Age Concern England that have been
publicised in newspapers in the United Kingdom, and it is part of the
charity's wider campaign to eradicate ageism in the health
service.
1 2
Last year the British Medical Association, the Resuscitation Council
(UK), and the Royal College of Nursing jointly said that do not
resuscitate orders could be considered only after discussion with the
patient or others close to the patient. Age Concern's dossier is
evidence this guideline is being flouted.
Resuscitation after a cardiopulmonary arrest is effective in only one
in five patients.3 Although it may be appropriate to
withhold resuscitation when a patient is dying, failure to involve
patients in decisions on do not resuscitate orders negates their
autonomy. It is most unfair for age to be used as a criterion to
withhold cardiopulmonary resuscitation. Most patients and relatives consider that discussions about death and do not resuscitate orders are
essential aspects of planning their care.4 It is doctors and nurses who find such discussions painful.
Do not resuscitate orders are increasingly used and have greater
implications than merely not calling the resuscitation
team.5 The do not resuscitate orders in Age Concern's
dossier came to light when complaints about quality of care were
investigated. So is there evidence that do not resuscitate orders that
are made without patients' or relatives' consent are a barometer for
unethical, inadequate care?
Over two thirds of patients with do not resuscitate orders are not
involved in making these decisions.6 These decisions not
to resuscitate, when reviewed, are poorly understood by patients; information given is not recalled; and viewpoints may
change.
4 7
After adjustment for disease severity,
prognostic factors, age and other covariates, patients given these
orders are more than 30 times more likely to die, suggesting that do
not resuscitate orders may reduce quality of care.8 Do not
resuscitate orders are more commonly used for older people and, in the
United States, for black people, alcohol misusers, non-English
speakers, and people infected with human immunodeficiency
virus The failure of health professionals to follow guidance for the use of
do not resuscitate orders is part of a wider concern over ageism in the
NHS. Ageism in cardiology is well documented and reflects ageism in
society.10 Although the Royal College of Physicians
acknowledged in 1991 that chronological age is not as important as
disease severity and comorbidity in determining ability to benefit from
treatment, this principle is still not applied in
practice.11 Other specialities, including primary care,
are not innocent of age discrimination. A survey by Age Concern found
that 1 in 20 people aged over 65 had been refused treatment by the NHS,
and 1 in 10 of those aged 50 or older felt that the health service
treated them differently because of their age.2
What more can be done? The usual hopeless solution MRC Health Services Research Collaboration, Department of
Social Medicine, University of Bristol, Bristol BS8 2PR
suggesting that doctors have stereotypes of who is not worth
saving.
5 9
audit, training and
education, more researchare even less able to deal with ageism. Our
attempts over the past three decades to produce humane doctors and
nurses, capable of responding to patients' needs regardless of age,
have not been rewarded.12 Medical students still rejoice
in their stereotypes of "geriatric crumble" and "GOMER"
(get out of my emergency room) patients. Leadership, vision, and
resources are needed to deal with marginalised people in our society.13 The first steps in making progress is to
acknowledgeat the highest levelthat stereotyping on the basis of
age exists and is unjust.14 Eradicating ageism in the NHS
will almost certainly require legislation.
SE is an unpaid member of a national advisory committee of Ageing Well UK, Age Concern England.
| 1. | Mendick R, Dillon J. Fifty elderly on NHS death dossier. Independent on Sunday 2000 April 16:1. |
| 2. |
Age Concern England.
Turning your back on usolder people and the NHS.
London: Age Concern, 2000.
|
| 3. |
De Vos R, Koster RW, de Haan RJ, Oosting H, van der Wouw PA, Lampe-Schoenmaeckers AJ.
In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome.
Arch Intern Med
1999;
159:
845-850 |
| 4. |
Krumholz HM, Phillips RS, Hamel MB, Teno JM, Bellamy P, Broste SK, et al.
Resuscitation preferences among patients with severe congestive heart failure: results from the SUPPORT project. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.
Circulation
1998;
98:
648-655 |
| 5. | Shepardson LB, Youngner SJ, Speroff T, O'Brien RG, Smyth KA, Rosenthal GE, et al. Variation in the use of do-not-resuscitate orders in patients with stroke. Arch Intern Med 1997; 157: 1841-1847[Abstract]. |
| 6. | Levin JR, Wenger NS, Ouslander JG, Zellman G, Schnelle JF, Buchanan JL, et al. Life-sustaining treatment decisions for nursing home residents: who discusses, who decides and what is decided? J Am Geriatr Soc 1999; 47: 82-87[Medline]. |
| 7. | Sayers GM, Schofield I, Aziz M. An analysis of CPR decision-making by elderly patients. J Med Ethics 1997; 23: 207-212[Abstract]. |
| 8. | Shepardson LB, Youngner SJ, Speroff T, Rosenthal GE. Increased risk of death in patients with do-not-resuscitate orders. Med Care 1999; 37: 727-737[CrossRef][Medline]. |
| 9. | Thompson BL, Lawson D, Croughan-Minihane M, Cooke M. Do patients' ethnic and social factors influence the use of do-not-resuscitate orders? Ethnicity Dis 1999; 9: 132-139[Medline]. |
| 10. |
Bowling A.
Ageism in cardiology.
BMJ
1999;
319:
1353-1355 |
| 11. | Royal College of Physicians. Cardiological interventions in elderly patients. A report of a working group of the Royal College of Physicians. London: RCP, 1991. |
| 12. |
Ebrahim S.
Demographic shift and medical training.
BMJ
1999;
319:
1358-1360 |
| 13. |
Smith R.
Medicine and the marginalised.
BMJ
1999;
319:
1589-1590 |
| 14. |
Tonks A.
Medicine must change to serve an ageing society.
BMJ
1999;
319:
1450-1451 |
© BMJ 2000
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