Do not resuscitate, or flyBMJ 2006; 332 doi: http://dx.doi.org/10.1136/bmj.332.7539.0-f (Published 23 February 2006) Cite this as: BMJ 2006;332:0-f
- Fiona Godlee, editor ()
Unless you're an economist, health economics is likely to leave you cold. But as Stuart Peacock and colleagues remind us this week (p 482), needs will always outstrip resources. So however hard it is to prioritise, that's what we have to do. Their essay offers help to doctors and managers wanting to make practical and ethical decisions about priorities. Their recipe for more holistic resource management includes clear objectives, ownership of decisions, and transparency.
These building blocks take time for careful thought, something that is often in short supply when dealing with acutely ill patients. All the more reason to have clear policies in place so that health professionals don't have to make hard decisions in the heat of the moment. Without these, there is a tendency to intervene even where this may be hopeless. Simon Conroy and colleagues (p 479) argue that resuscitating frail elderly people is rarely successful, especially in residential care homes, and it diverts resources from other aspects of care. It can also cause indignity at death for the patient and distress to staff. They say that current UK guidelines, which presume that patients should be resuscitated unless they have clearly requested otherwise, are inappropriate where success is so unlikely.
Asking what patients want should be easy, but doing this when it is most relevant—during acute admission to hospital—turns out to be hard. Helen Fidler and colleagues asked themselves why so few patients admitted through their emergency department were asked their views within the first 24 hours (p 461). Was this due to medical paternalism? Their study concludes not. They list a range of practical difficulties that need to be overcome to improve the chances that patients are asked their views. But they conclude that, until patients are well enough, health professionals must act in their best interests. Conroy et al agree and provide a “best interests checklist” (p 480).
Charges of paternalism will remain unless there is transparency. Patients must, as far as possible, understand the limitations of what is available to them. If a residential care home decides not to fund resuscitation, this policy needs to be explicit so that patients and their families can choose alternatives where these exist (p 479). Where new approaches to antenatal chromosomal testing would save money but would miss a small proportion of normal fetuses (p 452), parents need to know so they can pay for comprehensive testing if they wish (p 433).
Finally, things may be available but that doesn't mean we should use them, metformin and cheap air flights being two examples. Metformin increases fertility in obese women with polycystic ovary syndrome. But Adam Balen and colleagues are concerned about the risks of pregnancy associated with obesity (p 434). They advise waiting until the woman has lost weight before treating her infertility. As for the cheap air flights, you'll understand when you've learnt how to speak carbon (p 497).