Do not resuscitate decisionsBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7278.102/a (Published 13 January 2001) Cite this as: BMJ 2001;322:102
All rapid responses
‘Do Not Resuscitate’ Instructions: a measure of our practices.
To the Editor,
Doctors have been held accountable on ‘do not resuscitate’ (DNR)
instructions with relatives and patient survivor groups denying the
awareness of such orders and Age Concern suggesting decisions were
stereotyped to age [1,2]. The editorial  by Professor Ebrahim supported
the allegations and re-emphasised that DNR instructions reduced the
quality of care as, when adjusted for factors including age and severity
of disease, these patients were 30 times more likely to die . The
public perception has been of junior doctors making unsupervised decisions
on the elderly and on patients with malignant disease. Correspondence to
yourself  has highlighted anxiety and argument from opposing sides.
Importantly, the seriousness and sensitivity of issues have been raised,
as have the expression of appropriateness and duty of care, the
limitations to what can be achieved and the need for sound reasoning
which should always be part of such decisions. Several NHS Trusts will be
re-evaluating and re-assessing their own guidelines or recommendations on
resuscitation decisions and we report a limited prospective audit
identifying the extent of DNR decisions, relating these to the outcome a
month later and reviewing the decision mechanism.
On 25th May 2000, all inpatients (current and new, n=106, age range
23 to 97 years) within the medical directorate (unselected adult take) at
this hospital were identified and their current hospital records examined.
Of these, 11 (10.4%) had a DNR decision recorded. 10/11 of these were aged
>70 years (representing 60% of study group). All these had chronic
debilitating illness including severe cerebrovascular accidents, multiple
sclerosis, dementia, overwhelming sepsis, end-stage congestive cardiac
failure, chronic renal impairment, or severe chronic obstructive pulmonary
disease. A month later, 5/11 of these patients had died in hospital, three
were discharged to nursing homes, one was discharged home, and two
remained inpatients. Of the original 106 patients, 13 had died; in
addition to the five initially DNR, five more had been made DNR (three
with advanced metastatic cancer, two with multiple chronic pathologies
requiring full time care), two did not have cardiopulmonary resuscitation
(CPR) initiated for various reasons, and one had a failed CPR. Assessing
all 16 patients on whom a DNR decision had been made, for seven the
decision was made within 24 hours of admission, for five within ten days,
and for four more than ten days later. For six patients the initial
decisions were made by the consultant, for five by the registrar, for
three by the senior house officer, and for two the documentation was not
clear. For at least 10/16 patients (where recorded) the DNR decision had
also been discussed with the relatives. There were no recorded discussions
with patients (though five patients were unconscious or had impaired
mental function). Of those who died, time after DNR decision varied widely
from 1 to 31 days. Of the 14/106 patients with diagnosed malignant
disease, seven had metastases but only three of these had been made DNR.
This audit suggested a DNR decision was made on a small number of
appropriately assessed patients. Decisions disproportionately involved
more of the elderly patients who had significant co-morbid illnesses.
There was not a lower threshold for patients with malignant disease.
Supervision of junior medical staff could have been better documented (as
seniors agreed with the decisions) as could have been all discussion with
relatives and the reasons from which decisions are made. Whether DNR
decisions were being made frequently enough, however, who should be
involved in the process, and importantly the ethics of why patients were
not being involved in the decision making roles, require further
No conflict of interest
1 Mendrick R, Dillon J. Fifty elderly in NHS death dossiers.
Independent on Sunday 2000. April 16:1
2 Age Concern England. Turning your back on us-older people and the
NHS. London: Age Concern, 2000.
3 Ebrahim S. Do not resuscitate decisions: flogging dead horses or a
dignified death. BMJ 2000;1155-56.
4 Shepardson LB, Younger SJ, Sperolt T, Rosenthal GE. Increased risk
of death in patients with do-not-resuscitate orders. Med Care 1999;37:712-
5 Do not resuscitate decisions. BMJ 2001:322;102
Competing interests: No competing interests
Editor - I realise that the BMJ must consider different points of
view in it's letters section but the letter from Gross (1) has frankly
alarmed me. Are we so divorced from the general public that they honestly
believe the things
asserted in this letter? I am not aware that Resuscitation Guidelines are
rhetoric nor that they have been formulated without thought. Each case
should be considered as an individual and, yes, age may come into it.
Elderly people have special needs and risks specific to their age group.
This is why Elderly Specialists have come into being and it is a full time
task ensuring that one keeps up to date with relevant research and
improving practice. I am sure you won't publish this comment but I find
it frankly insulting to see written that 'treating elderly patients and
their relatives with total disrespect' is current practice.
have an important part to play in caring for elderly people both in an out
of hospital and I
(and I believe the majority of my colleagues)would never diagnose and
institute treatment without making every effort to involve them. However
in law they cannot consent on behalf of their relative for an operation or
a course of ECT and I cannot see that it should be a requirement for them
consent to witholding cardiopulmonary resuscitation. What will happen if
relatives have not made it to the hospital in time to decide whether CPR
should be atttempted? Should we put the patient on a ventilator until
they get there, thereby exposing the relatives to the horrendous
responsibility of having to decide whether to switch it off again? What if
they then decide not to switch it off? The risk of legislation, I
believe, is that we will no longer be able to consider people as
individuals, to weigh up the risks and benefits of attempting CPR before
coming to a decision.
Working in psychiatry I am often involved with patients and relatives
suffering from differing degrees of anxiety and distress. The thought of
administering a questionnaire at every admission asking the patient (or
presumably their relative) their attitude to resuscitation, whether they
have a living will (not something, as far as I am aware, I am allowed to
consider in law) and if they consider starving to death acceptable, is
absolutely incredible. Who is to be considered in this questionnaire,
everyone over 65years, everyone with an untreatable condition, everyone
is fortunate enough to be conscious or compus mentis at the time of
admission? I would also refute the claim by Gross that any do not
reuscitate decision made without discussion is unethical.
It is unethical
not to consider the case of each individual. It is unethical to consider
the wishes of relatives as paramount when their relationship with the
patient may be less than supportive. In all cases the patient is the
person to be considered. Some patients do not want very much information
about their condition and it is our responsibility to consider what they
are telling us about how much they want to know.
I too, am not surprised there appears to be so much demand for the Patient
Concern leaflets (2 & 3) 'How to survive surgery' and 'How to survive
doctors' by their very titles they imply that if one doesn't read them
they may not survive! Please give us some credit for wanting to do our
very best for our elderly patients.
SHO in Psychiatry
Queen's Medical Centre, Nottingham NG2 7AA
1. Gross R. Without discussion, these orders are unethical at
any age. BMJ 2001;322:105.(13 January).
2. Robins J. How to survive surgery. London:Patient Concern,
3. Robins J. How to survive doctors. London:Patient Concern,
Competing interests: No competing interests