Intended for healthcare professionals

Views & Reviews Personal views

Who is responsible for do not resuscitate status in patients with broken hips?

BMJ 2007; 334 doi: (Published 18 January 2007) Cite this as: BMJ 2007;334:155
  1. Rahij Anwar, specialist registrar RahijAnwar@aol.com1,
  2. Azeem Ahmed, senior house officer, West Middlesex University Hospital2
  1. 1South East Thames Region
  2. 2Middlesex

    Hip fractures are on the rise in the ageing population of our country. It has been estimated that about 30-40% of these patients die within the first year. Although actual perioperative causes of mortality are difficult to ascertain, it is generally believed that a vast majority of early deaths occur due to medical conditions such as chest infection and fluid and electrolyte imbalance. Better outcomes have been reported in centres where the management of these patients is carried out jointly under the medical and orthopaedic teams. However, lack of resources, poor co-ordination between the orthopaedic surgeons and medical teams, and ever increasing patient load often affect the quality of treatment that these frail patients deserve.

    When elderly patients with hip fractures become acutely unwell during the perioperative care and their chances of survival seem bleak, the whole medical workforce including orthopaedic surgeons, anaesthetists, and physicians unanimously agree that cardiopulmonary resuscitation should not be performed in the event of an arrest. However, none is ready to make a firm decision in relation to individual patients and as a result sometimes patients as old as 95 years are subjected to the trauma of cardiopulmonary resuscitation, which they would never have agreed to if they were mentally competent to make a final decision.

    The physicians, who get only temporarily involved in their care for many reasons, are not always willing to establish the “do not resuscitate” status themselves. They strongly believe that this decision is actually the responsibility of the admitting orthopaedic team, who are considered to be in overall charge of the care of these patients.

    The orthopaedic surgeons, on the other hand, find themselves in a “tight spot” as they are unclear of the consequences of such a decision. Some argue that the “do not resuscitate status” is usually misunderstood as “discontinuation of active treatment,” especially by the nurses, which significantly compromises patient care. There are also fears that such an approach may become indefensible in a court of law.

    Looking at this problem from the relatives' perspectives also raises certain issues which can often prove quite challenging for doctors. Most relatives, when approached for a decision, assume that the patient is likely to die, although this may not always be the case. They also, therefore, regard the “do not resuscitate status” as a decision not to treat. As a result, some of them have even objected to the administration of intravenous fluids or antibiotics to patients after they had agreed to the “do not resuscitate status.” Such misinterpretations are often the result of poor communication, which can easily be improved. Rarely the relatives may mislead the doctors, especially if they have vested interests.

    All elderly patients should make an informed decision regarding “resuscitation status” in the presence of a doctor, on admission. If the patient is too mentally confused to give informed consent, this decision should rest with the team responsible for the patient's care, in consultation with the relatives. It must be remembered that the timing of this decision is extremely important, for any delay will result in confusion and misinterpretation, which can seriously compromise the quality of treatment. This decision should be clearly documented in the medical notes, and all consent forms for hip operations should have a statement confirming the resuscitation status of the patient. This can also be universally applied to all other operations in elderly patients. This would ensure that each patient gets what he or she (or the relatives) has opted for and active treatment would continue to be delivered irrespective of the resuscitation status.

    Physicians and orthopaedic surgeons should join hands to provide the best possible care to these elderly patients, who need much more than just a simple hip operation.

    Lack of resources, poor co-ordination between the orthopaedic surgeons and medical teams, and ever increasing patient load often affects the quality of treatment that these frail patients actually deserve

    View Abstract