Intended for healthcare professionals

Editorials Christmas 2011: Editorial

Death can be our friend

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d8008 (Published 21 December 2011) Cite this as: BMJ 2011;343:d8008

Re: Death can be our friend

Enkin et al make a passionate plea for embracing the inevitable death as our friend [1]. Perhaps, we should start by accepting death in those who have already died.

Cardiopulmonary resuscitation (CPR) is now extensively used in Hospital setting. The oncologists are not obliged to talk about futile surgery, futile radiotherapy or even phase one trials of chemotherapy with dying cancer patients. But oncologists and even Hospice clinicians are obliged to document a 'Do Not Resuscitate' (DNR) decision for cancer patients.

The TV dramas have raised the expectations of general public regarding the outcome of a CPR. Quite often patients and family are distressed by this ‘DNR’ discussion/decision and some feel an effective treatment is being withdrawn. [2]

Unfortunately, the national guidelines endorsed by BMA do advocate ‘Advance care planning’ for cancer patients while at the same time stating that ' it is not necessary or appropriate to initiate discussion with the patient to explore their wishes regarding CPR' if CPR will not be successful [3]. Moreover in practice, most hospital guidelines do advocate CPR discussion with patient and family.

All prescriptions in an oncology ward are not done by default; it is done by active prescription. Perhaps we should start by positively documenting and prescribing ‘PRN’ CPR for the minority who is ‘for CPR’ in an oncology ward and spare the majority from the ‘Presumption in favour of CPR when there is no DNAR decision’ as advocated by the guidelines. [4][5]

REFERENCES:

1 Enkin M, Jadad AR, Smith R. Death can be our friend. BMJ 2011;343:d8008.
2 NHS hospitals warned over “do not resuscitate” orders. the Guardian. 2011.http://www.guardian.co.uk/society/2011/dec/05/nhs-hospitals-warned-resus... (accessed 25 Dec2011).
3 Decisions Relating to Cardiopulmonary Resuscitation .A Joint Statement from the British Medical Association, Resuscitation Council (UK ) and the Royal College of Nursing. 2007.
4 Ewer MS, Kish SK, Martin CG, et al. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer 2001;92:1905–12.
5 Heath I. Opt in not out. BMJ 2011;343:d5251.

Competing interests: No competing interests

26 December 2011
S SUNDAR SANTHANAM
Consultant Oncologist
Nottingham University Hospitals NHS trust
Hucknall Road, Dept of Oncology, Nottingham NG5 1PB