Rigid discussion process before making these decisions may cause distress

EDITOR—Ebrahim 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 …