Letters

An unmerciful end

Decisions not to resuscitate must not be left to junior doctors

Society must show respect for people who are dying

Decisions not to resuscitate must not be left to junior doctors

EDITORSoper's harrowing description of an elderly woman's "unmerciful end" after cardiopulmonary resuscitation by a team of paramedics raises many ethical issues about what constitutes a dignified, natural death.¹

My research group runs training courses in communication skills for healthcare professionals working in oncology. We have been dismayed by the number of specialist registrars and senior house officers working at a large, famous cancer institution who have asked us recently for help about discussing "do not resuscitate" decisions with patients who are dying. The BMA guidelines recommend that consultants should have ultimate responsibility for this onerous and sometimes deeply distressing task, but in reality it falls on their juniors.

As we worked with our team of simulated patients (actors) on different scenarios that the doctors had had to confront, the actors expressed incredulity that this should even be a topic for discussion with patients. Who in their right mind would consider cardiopulmonary resuscitation to be a reasonable, humanitarian act to perform on a patient, whatever age, with widespread metastatic disease nearing the end of his or her life?

Central to the ethos of my research group is the premise that patients have a right to honest information, to discuss their concerns and worries about death, and to choose where they die, with the appropriate care and support. I do not think that this should include hypothetical discussions about a management that most would agree to be inhumane. Any armchair ethicist who suggests that these conversations should take place with dying people should try doing it.

The guidelines and directives might well be appropriate for some situations, but I wonder just whose interests are really being served. If it is indeed necessary to have do not resuscitate preferences recorded in the hospital notes then such sensitive and distressing issues should not be left to untrained junior doctors.

Lesley Fallowfield, director. 
CRC Psychosocial Oncology Group, School of Biological Sciences, University of Sussex, Brighton BN1 9QG L.Fallowfield{at}biols.susx.ac.uk

Society must show respect for people who are dying

EDITORA true mark of a society is how it deals with its dying. As Soper's story illustrates, we sometimes do very badly.¹ In her rapid response to Soper's piece² [published here as the letter above] Fallowfield writes, "Who in their right mind would consider [cardiopulmonary resuscitation] a reasonable, humanitarian act to perform on a patient, whatever age, with widespread metastatic disease nearing the end of [his or her] life?"

I agree wholeheartedly with Fallowfield. There are some things that professional training and experience teaches us that do not need to be discussed with patients. But this view is not held by everyone. Contributing to the discussion after an editorial on do not resuscitate orders, Roger Goss, director of Patient Concern, wrote, "Do not resuscitate orders at any age, without discussion, are unethical. Eradicating this practice in the NHS requires legislationfull stop."³

If this view becomes more widespread Soper is right to worry about the lurking legal profession, and there will be many more relatives denied the right to say goodbye to their loved ones in peace.

Neville W Goodman, consultant anaesthetist. 
Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB Nev.W.Goodman{at}bris.ac.uk