Views of elderly people on living wills: interview study
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7250.1640 (Published 17 June 2000) Cite this as: BMJ 2000;320:1640
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
In a week when the media seemed particularly bulging with NHS
stories, “The Trust” (Channel 4, 7 February 2002) questioned the wisdom of
talking to older patients about whether or not they wished resuscitation
to be attempted in the event of cardiac arrest. Unfortunately, the two
main messages of this otherwise fascinating programme were that it is
invariably cruel to talk about resuscitation and choice, particularly to
older people who often prefer doctors to decide for them, and the
implication that the whole topic of end of life should be generally
avoided as patients do not want to think about how they will die. A study
in this journal in June 2000 found that 74% of older people surveyed (when
approached appropriately) were interested in making choices themselves and
the concept of advance directives (‘living wills’).
Sensitive preparation and good communication skills are required.
There is no reason why patients who are willing should not be engaged in
prior discussion of treatment (and non-treatment) options, including
whether they would want resuscitation to be attempted. Indeed evidence on
‘expert patients’ shows that involving people in decisions about their
care does have a beneficial effect on health outcomes. The likelihood of
successfully restarting a patient’s heart and breathing in a resuscitation
attempt is difficult to predict with absolute accuracy, and it is
obviously not necessary to discuss with patients all the procedures that
would clearly be futile in their case. But many people of all ages would
like to be consulted about their willingness to risk the burdens of
cardiopulmonary resuscitation (CPR) if there is some genuine chance of it
succeeding. We do recognise, however, that discussion of attempting CPR
can be very difficult for patients and health professionals alike. It is
important that decisions to discuss such sensitive issues are not made on
the basis of a person’s age alone.
Following concerns that older patients were rarely asked their views,
the BMA, Resuscitation Council (UK) and Royal College of Nursing last year
updated their joint statement on decisions relating to cardiopulmonary
resuscitation. The Department of Health recommends the statement as a
basis for local policies. A key message of the joint statement is that
patients should be given the opportunity to be involved in decisions about
their care.
We believe that written information about how decisions about CPR are
made, addressing the questions patients ask, or might want to ask, can
facilitate discussion. It is problematic that the success rates of CPR are
misrepresented in the media and that the likelihood of success is
sometimes hard to predict. In an effort to help, the BMA has written a
model information leaflet for patients which addresses the questions
patients ask, or might want to ask, about how resuscitation decisions are
made. The leaflet will be published in the spring.
Yours faithfully
Dr Michael Wilks
Chairman, Medical Ethics Committee
British Medical Association
Mr Gordon Lishman
Director General, Age Concern England
Dr Bob Bingham
Chairman, Resuscitation Council (UK)
Dr Beverly Malone
General Secretary, Royal College of Nursing
Competing interests: No competing interests
My purpose for having a Living Will is: Given the cost of extended
Hospital stays, I prefer not to bankrupt my estate by surviving a
catastrophic/long term illness, i.e., cancer or illness of equal severity.
Further, if I have reached a point where life support is necessary, it is
preferable to die. I consider life support to be nothing short of
degrading (to humans). I am 62, have had a great life, illness free, am
very active. Anything less is unacceptable. It is my body, my decision.
Competing interests: No competing interests
Sir
The paper by Schiff et al [1] and the editorial by Emmanuel [2] show
how easy it is to think that living wills provide good and simple answers
to end of life planning for the elderly. Although Schiff et al reported
that elderly people had clear views on the issues raised, it would be
wrong to accept their results uncritically.. They found that more than
half of the people questioned said they would not want treatment for
pneumonia if they were doubly incontinent. Although it is not stated, the
assumption that non treatment would lead to death and not worsened
disability (perhaps the most likely outcome), seems to be presumed. Even
if that assumption were correct, it is very clear that once patients have
actually become doubly incontinent their choices are different from those
made by the healthy. I think the authors would be very hard put to find an
otherwise healthy group of elderly people who are currently actually
doubly continent of whom 53% do not wish to live.
The limitations of advance directives in the elderly have already
been discussed [3]. Given their dangers and shortcomings, it is very
fortunate that the UK Government has decided not to legislate to make them
legally binding. Although such discussions such as those described in
Emmanuel's editorial may be of some help, that fact that the healthy do
not make the same choices as the sick means that advance directives must
be interpreted with great caution. Simple and sensible ways of
challenging them are also required [3]. If the patients in Schiffs study
were to be bound by their statements after they lost capacity, they might
be greatly harmed by decisions whose effects they never intended..
Adrian Treloar
Consultant and Senior Lecturer in Old age Psychiatry
Oxleas NHS Trust and Guys Kings and St Thomas Medical Schools
Memorial Hospital,
London SE18 3RZ
1. Schiff R, Rajkumr C, Bulpitt. Views of eldeerl pople on living
wills: interview study. BMJ 320 : 1640-1
2. Emmanuel L. How living wills can help doctors and patients talk about
dying. BMJ 320 : 1618-9.
3. Treloar A. Advance directives: limitations upon their applicability in
elderly care. International Journal of Geriatric Psychiatry(1999); 14:
1039- 1043.
Competing interests: No competing interests
Resuscitation for all?
The determination of an in-patient's resuscitation status continues
to trouble health workers and the general public alike. There is a
recurrent theme of failure to communicate adequately on the part of the
medical profession versus failure to understand the rationale behind DNR
orders on the part of the public. Having worked as a junior doctor
involved in resuscitation teams for the past 8 years, I have rehearsed
many of the arguments from both sides in discussions with relatives and
colleagues. Through all the agonising over informed consent and patient
advocacy, when was it decided that resuscitation attempts should be
rationed at all? There was always a familiar, irrational sentiment
expressed that resuscitation was "undignified" and "not the way to die"
and that seemed to be the catalyst for increasing DNR orders based on age
and underlying diagnosis. The perception that outcome was being balanced
against the unpleasant nature of the resuscitation efforts appeared to be
the driving force behind not initiating a "crash-call". Since cerebral
anoxia is the mode of death the likelihood of the patient suffering
inordinately during the resuscitation efforts seems nonsensical and the
concept of "dignity" was principally in the eyes of those calling for or
conducting the resuscitation attempt. If I arrest in the street tomorrow,
there will be no agonising over my likely outcome by the public or
ambulance crew. They will simply initiate CPR to the best of their
ability. This seems to me to be the simplest, most ethical, most logical
route to take. Why not agonise over the patient's health after the CPR
attempt has concluded? This would eliminate 95% of the subjects involved,
avoid the debate about who "merits" CPR efforts and allow a greater focus
on outcome for those who survive the initial efforts.
The outcome for any cardiac arrest is difficult to determine and that
is the core of the ethical dilemma behind whether to attempt
resuscitation. On that basis alone we should not have attempted to ration
CPR but continued to offer it to all unless they specifically decline.
This approach would I believe afford the same discussion with relatives
and the patient about the merits of a DNR order, but begin with the
premise that resuscitation was the norm and not a priviledge afforded only
to the young and the healthy.
Competing interests: No competing interests