Letters

Do not resuscitate decisions

Rigid discussion process before making these decisions may cause distress

Resuscitation should not be part of every death

Focus should be on offering treatments appropriate to diagnosis and regardless of age

Cardiopulmonary resuscitation seems to be exempt from scrutiny of evidence based medicine

More consumer education and involvement are needed

Sound clinical reasons for withholding cardiopulmonary resuscitation must not be confused with ageism

Not discussing decisions is often because of practicalities, not ageism

We need a consistent message

Doctors must always act in their patients' best interests

Inadequacies of palliative care system need to be tackled

All -isms are intolerable

Without discussion, these orders are unethical at any age

Summary of rapid responses

Rigid discussion process before making these decisions may cause distress

EDITOREbrahim writes about do not resuscitate decisions.¹ Elderly patients and their relatives overestimate the success of cardiopulmonary resuscitation,² as do doctors and nurses.³ Healthcare professionals need to be realistic about the poor success rate. Only 10-20% of all those in whom cardiopulmonary resuscitation is attempted in acute general hospitals will live to be discharged.⁴ Selected elderly patients can do as well as younger patients, and old age should not be used as a basis for a do not resuscitate order, but elderly patients with chronic illness probably have less than 5% survival to discharge.⁵

Resuscitation is a medical treatment, and as with other treatments there are times when it will be futile and therefore inappropriate. We should discuss resuscitation when do not resuscitate orders are made on the basis of quality of life or the patient wants to discuss it. When resuscitation is thought to be medically futile, however, is it right to discuss this treatment; might it be distressing to the patient?

The skill of the doctor is in providing, and telling the patient about, treatments that are most appropriate, using all the available information, including the views of the patient. As with other treatments, the degree to which the patient wishes to become involved in this process varies considerably. One study of elderly patients receiving acute medical care and rehabilitation showed that only 57% actually wanted some involvement in making the decision on cardiopulmonary resuscitation.²

The requirement for a rigid discussion process before a do not resuscitate order is made would cause needless distress to some people nearing the natural end of their life due to inexorable and irreversible processes of disease. We should do everything we can to preserve a humane approach to dealing with patients and carers at this time of ultimate emotional vulnerability.

Tom Downes, specialist registrar in geriatric medicine. 
Jane Liddle, consultant geriatrician. 
b.j.liddle{at}sheffield.ac.uk Northern General Hospital, Sheffield S5 7AU

Resuscitation should not be part of every death

EDITORPioneers of cardiopulmonary resuscitation in the 1960s were medical heroes. They would be surprised to find their treatment for hearts that were too young to die becoming an obligatory death rite for all, and themselves anathematised for mentioning the new taboo of age.¹

Feedback that I, as chairman of Tayside cardiopulmonary resuscitation committee, receive from junior hospital staff is that inappropriately initiated cardiopulmonary resuscitation is common, emotionally fraught, and demotivating; inappropriate failure to initiate cardiopulmonary resuscitation is virtually unknown. Seemingly false positive results therefore heavily outnumber false negative results, but parallel audits of deaths and cardiopulmonary resuscitation are now being conducted to relate the two.

Ebrahim wishes to increase cardiopulmonary resuscitation in elderly patients, recommending legislation and quoting American attitudes and evidence in support.¹ Attitudes and practices cannot be imported uncritically from the United States, a lawyer-ridden society. If they were, ward rounds would end up being led by civil rights lawyers, medical ethicists, and their interpreters. Doctors would then be informed what equity and empowerment obliged them to do, rather than use their clinical judgment, which balances potential benefit against potential harm.

Cardiopulmonary resuscitation appears miraculous; hence the view that there should be miracles for all on the NHS and that cardiopulmonary resuscitation is somehow different from other treatments in not being a matter for medical discretion. Behind this expectation are two sources of confusion.

According to the Oxford English Dictionary, resuscitation means restoring life from apparent death, with overtones of the resurrection of Christ.² Medical practice has introduced semantic confusion by corrupting the term to mean the often vain attempt to restore life. The second source of confusion is that cardiopulmonary resuscitation was developed to treat the effects of reversible precipitants of sudden death. Even in chronic progressive disease the transition to death is momentary and therefore sudden. This makes the distinction between sudden and non-sudden death arbitrary and difficult to define medically, or for would-be legislators. The potential for pressure groups to make a point by publishing details of unfortunate cases and selected case series to the detriment of public confidence is virtually unlimited.

Tayside resuscitation policy is to avoid the phrase "not for resuscitation" because of the semantic confusion and to write in the notes "cardiopulmonary resuscitation currently inappropriate: decided by [name], discussed with [names]. To be reviewed by [identify who] in/on [time interval or date]." The policy states that written instructions are not always possible and that judgment on treatment is the ultimate prerogative of the medical team, taking account of all the circumstances, which often change.

Hugh Tunstall-Pedoe, professor of cardiovascular epidemiology. 
University of Dundee at Ninewells Hospital, Dundee DD1 9SY h.tunstallpedoe{at}dundee.ac.uk

Focus should be on offering treatments appropriate to diagnosis and regardless of age

EDITORI am surprised at Ebrahim's views on resuscitation decisions.¹ Perhaps it should be remembered that cardiopulmonary resuscitation is designed to help patients with sudden collapse, usually due to acute myocardial ischaemia. The implication of Ebrahim and Age Concern² is that patients with a do not resuscitate order are condemned to die, not that they are individuals for whom this form of treatment is simply not indicated. The other implication is that cardiopulmonary resuscitation is usually successful; in fact, the outcome is often less than desirable. The fact that doctors can identify patients who are "30 times more likely to die" is probably an indication of doctors' skill and little else. Perhaps the reason that guidelines are not being followed is because they are flawed.

If Ebrahim and Age Concern wish to tackle ageism the focus should be to ensure that patients of any age are offered treatments appropriate to their diagnosis. Far more benefit could be gained, for example, by campaigning for stroke units than by campaigning for resuscitation of individuals with terminal, untreatable illnesses, regardless of age.

Dennis Briley, consultant neurologist. 
Stoke Mandeville Hospital, Aylesbury, Buckinghamshire HP21 8AL dennis{at}dbriley.fsnet.co.uk

Cardiopulmonary resuscitation seems to be exempt from scrutiny of evidence based medicine

EDITORI am surprised that Ebrahim should have used media comments about do not resuscitate instructions in patients' notes as the basis for a tirade against ageism in health care.¹ Whereas the risks and benefits of other medical interventions are subjected to the rigorous scrutiny of evidence based medicine, cardiopulmonary resuscitation seems to be exempt from this.

It is hardly surprising that the media should represent cardiopulmonary resuscitation as a good thing, which is being rationed according to the prejudices of the medical profession on the one hand and misguided attempts at cost containment on the other. Yet similar misconceptions seem to creep into more informed discussions.

If patients and families are to take an active part in difficult treatment decisions they need reliable information on the likely risks and benefits of each option. Unfortunately, the literature on cardiopulmonary resuscitation provides little firm evidence on which to base such decisions, particularly for elderly inpatients. Estimates of the success rate of cardiopulmonary resuscitation vary so widely, and definitions and selection criteria used in the studies are so diverse, that meta-analysis of absolute risks and benefits is meaningless.²

Although spontaneous recovery from apparent cardiac arrest is not uncommon, hardly any controlled studies have been carried out, and most of the observational studies have unquantifiable biases. Ebrahim implies that old age itself may not substantially affect the chances of successful resuscitation, but, because of the prejudice of which he complains, frailer elderly patients could have been excluded from the studies on which this conclusion is based.

Information about the risks of adverse effects of cardiopulmonary resuscitationa more distressing death, or survival with severe brain damageis hard to find, and these outcomes are hardly ever discussed with patients. The term "do not resuscitate" ignores these possibilities and implies that doctors can revive the patient if they so wish. It is hardly surprising that patients and families feel aggrieved if they are not consulted about do not resuscitate decisions. It is not known whether seriously ill patients would be keen to discuss the realistic question, "In the event of your sudden death occurring after a deterioration in your condition, should we make attempts at resuscitation, which would probably prove futile and cause distress to you and your family?"

Before we are compelled to spend scarce time raising complex and potentially frightening questions with patients before withholding a treatment that we think is inappropriate, more reliable evidence is needed about the risks and benefits of cardiopulmonary resuscitation.

David Barer, professor of stroke medicine and elderly care. 
Queen Elizabeth Hospital, Gateshead NE9 6SX d.h.barer{at}ncl.ac.uk

More consumer education and involvement are needed

EDITORIn response to Age Concern's campaign on cardiopulmonary resuscitation¹ we designed and completed an audit of the views of patients in our hospital. We conducted our questionnaire survey, administered by medical students, between 25 April and 1 May 2000 at a hospital for older people (aged >65) and stroke rehabilitation. We interviewed only patients who were documented as being for resuscitation in the event of a cardiorespiratory arrest.

Twenty eight patients were interviewed in the time available. Nineteen thought that cardiopulmonary resuscitation had a 50% or greater success rate. Eight considered that a "not for cardiopulmonary resuscitation" order would detrimentally affect their general care (six thought it could improve their care). Few (three people) thought that age should influence cardiopulmonary resuscitation status. Most (24) correctly recognised that doctors currently make the decisions on cardiopulmonary resuscitation, but in their opinion they and their relatives should be equally involved in the decision.

Our sample of patients had an overoptimistic view of the potential success of cardiopulmonary resuscitation. We also found that they may worry about the implications of their cardiopulmonary resuscitation status, as some were concerned that their further care might be adversely affected. The risks of discussing cardiopulmonary resuscitation status with patients need to be considered by all healthcare professionals. Overall, our survey supports the view that more consumer education and involvement are needed.²

Barbara Brett, medical student. 
Elizabeth J Peak, medical student. 
Arjun Nair, medical student. 
Medical School, University of Edinburgh, Edinburgh EH8 9AG

Richard I Lindley, consultant geriatrician. 
Royal Victoria Hospital, Edinburgh EH4 2DN ril{at}skull.dcn.ed.ac.uk

1.	Age Concern England. Turning your back on usolder people and the NHS. London: Age Concern, 2000.
2.	Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death. BMJ 2000; 320: 1155-1156. (29 April.)

Sound clinical reasons for withholding cardiopulmonary resuscitation must not be confused with ageism

EDITORContrary to Ebrahim's comments in his editorial,¹ the 1999 statement on cardiopulmonary resuscitation by the BMA, Resuscitation Council, and Royal College of Nursing does not demand discussion with the patient or close relatives before a do not resuscitate order can be considered.² Indeed, it seems totally inappropriate, illogical, unkind, and potentially unethical that healthcare professionals should be compelled to discuss any form of ineffective treatment with a patient. Furthermore, as healthcare professionals are not obliged to provide any treatment that cannot produce the desired benefit³ it seems particularly cruel to offer cardiopulmonary resuscitation in circumstances where evidence indicates that it will be ineffective and then to refuse to administer it anyway.

Age Concern's finding that elderly patients are given do not resuscitate orders does not necessarily suggest ageism. There is much evidence that elderly patients do receive cardiopulmonary resuscitation. Altogether 55% of patients in the British hospital resuscitation (BRESUS) study were aged over 65, with a quarter being over 75.⁴ I would suppose that when do not resuscitate policies were applied there were good clinical reasons for the intended withholding of cardiopulmonary resuscitation.

Gary B Smith, chairman of Portsmouth district resuscitation committee. 
Portsmouth Hospitals NHS Trust, St Mary's Hospital, Portsmouth PO3 6AD gary.smith{at}qmail01.porthosp.swest.nhs.uk

Not discussing decisions is often because of practicalities, not ageism

EDITORWe strongly support Ebrahim's attack on ageism in the health service but think that he was unwise to illustrate his point by referring to the use of do not resuscitate orders.¹ The situation is not nearly as clear cut as he would have readers believe.

We make resuscitation decisions regularly; we sometimes discuss these with relatives, less often with patients. The reasons for not discussing decisions have little to do with ageism and much to do with practicalities. Most survivors of resuscitation have their arrest on their first or second day in hospital, so decisions have to be made at a time when many elderly patients are legally incompetent to decide, either because of confusion or because of the severity of their illness. In a small British study most patients could not recall important details about resuscitation a week after the discussion.² We often try to contact relatives on these occasions, but this in itself causes problems. Under current law if patients are incompetent then responsibility for medical decisions passes to their doctors, not their family; many people are unaware of this.

What if decisions are made because resuscitation is so unlikely to succeed that it can be regarded as futile? Is there an obligation to tell patients or relatives about this (and other potentially lifesaving treatments that are to be withheld on this basis)? The most recent guidelines avoid giving a clear answer.³

Ebrahim states that most patients and relatives want to discuss death and do not resuscitate decisions, but this is not our experience and is not supported by the literature. We are regularly asked to avoid discussing diagnoses of cancer and other serious illness for fear of causing distress. British studies of patients' views about resuscitation are consistent with this; some patients want to be involved in decisions or have their relatives consulted and others do not, while some want doctors to decide.⁴ Heller et al became the subject of press criticism for attempting to discuss resuscitation with all elderly patients and were accused of rationing care and advocating euthanasia.⁵

Doctors who face these problems in their work would appreciate an editorial telling them how its author manages to discuss all the do not resuscitate decisions that he or she has to make and how the practical difficulties that we have described can be overcome.

Kevin Stewart, consultant geriatrician. 
Claire Spice, specialist registrar in general and geriatric medicine. 
Royal Hampshire County Hospital, Winchester, Hampshire SO22 5DG kevin.stewart{at}weht.swest.nhs.uk

We need a consistent message

EDITORI have recently researched the issue of resuscitation orders and agree with Ebrahim's sentiments concerning ageism, but I was disappointed that his editorial did not address many of the concerns of the public highlighted by the British media.¹ He did, however, make the comment that the orders "have greater implications than merely not calling the resuscitation team." This relates to a misconception that needs to be quashed in the eyes of both the public and a small element of the medical profession.

"Not for resuscitation" should mean just thatnot for cardiopulmonary resuscitation and not for advanced life support measures such as ventilation. It should not, however, cover other aspects of medical care unless they are specifically documented. Patients should still expect high levels of care, including antibiotics, fluids, and other drugs as well as palliation of symptoms. The literature suggests that this does indeed happen,² and patients need to be reassured accordingly.

Another important issue is that medical staff and the public should be informed about the procedure itself. Resuscitation is not often the quick and miraculous action seen in television programmes such as ER. The general consensus in the literature seems to be that although up to 30% of resuscitations are initially successful, less than 15% of those patients will survive to discharge.³ In certain groups, such as those with metastatic cancer,⁴ renal failure,⁴ septicaemia, and dependent functional status, this figure is in fact close to zero.

Clearly if medical practitioners are aware of these facts they are in a much better position to advise patients whether cardiopulmonary resuscitation is appropriate for them; patients greatly value doctors' advice on this issue.⁵ As far as possible the decision should be discussed with the patient and probably the family, although in clearly futile cases this may be inappropriate and unnecessary.

If these issues are addressed then the decision becomes easier to reach, is less contentious, and is less stressful for all parties. The fears that are hyped up in the media could be allayed if the public was reassured by a consistent message, given by the medical profession as a whole.

Adam Dangoor, registrar in oncology. 
Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand adangoor{at}paradise.net.nz

Doctors must always act in their patients' best interests

EDITORI am increasingly disappointed at efforts to remove the duty of care for patients from doctors into the hands of relatives or, even worse, the courts. I thought that I spent five years at medical school and 12 years in postgraduate training in order that I might have the knowledge and experience to care for patients in a professional manner. This means treating the patients when it is appropriate to do so and not treating them when it is inappropriate to do so.

Now I am being told that even when it may be clear to me that a patient will not benefit from treatment (in this case cardiopulmonary resuscitation¹) I must first ensure that this has been discussed with the family. How can family members have the required understanding of prognosis and treatment implications and the objectivity to make such a decision? What if the family disagrees? Am I then compelled to offer the futile treatment? Unfortunately, many doctors already seem to take this route; evidence the hopeless case in the intensive care unit, there because the family wanted everything done and now slowly dying without dignity.

Society is forgetting that death is an integral part of life and eventually comes to us all. It is becoming common practice for relatives, on finding someone dead at home, to call an ambulance. In the past it would have been the priest. Doctors' primary role is not to prevent death but to treat illness and alleviate suffering. Identifying patients for do not resuscitate orders is vital in modern high technology medical practice to prevent loss of dignity in otherwise inevitable deaths. Most patients with do not resuscitate orders will, I am afraid, be elderly with cancer, dementia, or other severe underlying illness limiting their life expectancy. This is not ageism but caring medical practice.

Michael O'Leary, staff specialist in intensive care. 
St George Hospital, Kogarah, NSW 2217, Australia m.oleary{at}unsw.edu.au

Inadequacies of palliative care system need to be tackled

EDITORI recently looked after my elderly grandmother while she died of an abdominal tumour. I observed with horror the multiple inadequacies of hospital care, particularly of palliation, nursing care, and communication. I saw the brutal process of means testing for essential social care, and the distress and inadequacy that resulted. A "good death" is often just an aspiration.

I can hardly believe that Age Concern and Ebrahim suggest legislation to prevent doctors from deciding to withhold cardiopulmonary resuscitation from very frail dying people without their consent or that of their relatives.¹ It is even more disturbing to read that the BMA and the health secretary have some sympathy with their case, suggesting mandatory discussion with the family and patient. How many lay people can differentiate between cardiopulmonary resuscitation and normal medical treatment? How many can weigh up the pros and cons in an individual case? Might relatives have other agendas? Would it not distress many people to be asked to take on such an emotional burden? Would this not shake confidence in their medical team and induce needless anxiety?

Ebrahim admits that cardiopulmonary resuscitation has a low success rate. This is particularly so in patients with severe terminal illness and very elderly and frail patients. Must we still go through a charade of cardiopulmonary resuscitation for these people if a misguided relative insists? What if an entirely perverse decision results and dying patients, like my grandmother, are forced to spend a few more pain wracked days on the ward? What if resuscitation is successful and a very old, frail, and terminally ill patient occupies a bed which is then denied to a 29 year old asthmatic patient, who then dies during a motorway ambulance journey to a distant hospital?

Ebrahim suggests that doctors have stereotypes of who is not worth saving, with racist and ageist tendencies. I suggest that when these decisions are made, probable outcomes are the main factor in doctors' decision making. When I made such decisions the patients involved invariably had advanced terminal disease, and this was the predominant factor in the decision. I and my colleagues were aiming to give them, and their families, the comfort of a good death.

Ebrahim's suggestion that making these orders is a barometer of unethical care is perverse. I disagree. I believe that a heavy handed approach via legislation will result in an increase in the sum total of human misery. Ebrahim and Age Concern could more profitably tackle the deep inadequacies of the palliative care industry that gave my grandmother such inadequate and flawed care.

M D Oliver, general practitioner. 
Browning Street Surgery, Stafford ST16 3AT mark.oliver{at}excite.co.uk

All -isms are intolerable

EDITOREbrahim's editorial on entrenched ageism shows the ugly side of medical practice.¹ Perhaps we cannot help it; we are humans and products of our time and culture. We are tribal creatures, and unless the forces maintaining tribalism are addressed it will remain.

Working among people who have problems with alcohol, other drugs, and mental health, my colleagues and I see classism, ageism, and racism daily. My belief is that our culture has defined which health problems are "more unpleasant" and which are "less unpleasant"; not surprisingly, the nicer ones are those that the vocal, well connected, well off middle class have. They can usually be externalised and treated with high tech, high cost interventions. Heart disease and certain cancers are in this group. But younger, less vocal people with drug problems or mental health problems are not in this group; their problems are "internal" problems, perhaps due to moral weakness (yes, even in this enlightened age) and not at all pleasant. Ignore them if possible, even if these problems are the most important of all health issues for the global burden of disability.

What of Virchow's admonition that we are the natural attorneys of the poor and should solve social problems? It's not just ageism we should fight, it's all of the -isms, now creeping back into a surgery or hospital somewhere near you.

Rod MacQueen, visiting medical officer. 
Lyndon detox, Orange, NSW, Australia randjmac{at}ix.net.au

Without discussion, these orders are unethical at any age

EDITORThe subheading to Ebrahim's editorial on do not resuscitate decisions is: "Resuscitation should not be withheld from elderly people."¹ Surely doctors should say instead that resuscitation must not be withheld. . . ." Ebrahim spells out the reality hiding behind the rhetoric of the BMA, Resuscitation Council (UK), and Royal College of Nursing. It would help if hospitals were required when booking in patients to offer them the opportunity to complete a form indicating, among other things, their attitude to resuscitation, whether they have a living will, and if they consider starving to death (under certain circumstances) to be acceptable.

The current practice of treating elderly patients and their relatives with total disrespect negates every principle of what constitutes a civilised health service. It is hardly surprising that Patient Concern is being inundated with requests for its "How to Survive" leaflets by people terrified at the prospect of having to go into hospital.^2-4 (Each leaflet is available from the organisation for two first class stamps.) I would add only that the usual hopeless solution includes guidelines.

Do not resuscitate orders at any age, without discussion, are unethical. Eradicating this practice in the NHS requires legislation, full stop.

Roger M Goss, director. 
Patient Concern, PO Box 23732, London SW5 9FY rogerconcern{at}hotmail.com

Summary of rapid responses

We posted 50 rapid responses by 49 correspondents from 27 April to 5 June 200032 responses by 12 May.¹ The responses were serious and thoughtful, and we found it difficult to choose which ones to publish here. In addition, we were unable to post several other responses mentioning specific cases of patients who had died because of the difficulties in obtaining consent from the patients' relatives.