Traditionally clinicians have determined their patients' resuscitation status without consultation. This has been condemned as morally indefensible in cases where not for resuscitation (NFR) orders are based on quality of life considerations and when the patient's true wishes are not known. Such instances would encompass most resuscitation decisions in elderly patients. Having previously involved patients in CPR decision-making, we chose formally to explore the reasons behind the choices made. Although the patients were not upset, and readily decided at the time (...) of initial consultation, on later analysing the decision-making we found poor understanding of the procedure, poor recall of information given and in some cases evidence of harm. This may be attributed to impaired decision-making capacity of elderly hospitalised patients as previously shown, or to the discomfort precipitated by having to contemplate the apparent immediacy of cardiac arrest by these patients. We propose that subscribing to autonomy as a general principle needs to be balanced against particular cases where distress may be caused by, or result in, diminished competence and limited autonomy. (shrink)

One hundred inpatients on an acute hospital elderly care unit and 43 of their relatives were interviewed shortly before hospital discharge. Eighty per cent of elderly patients and their relatives were aware of cardiopulmonary resuscitation (CPR). Television drama was their main source of information. Patients and relatives overestimated the effectiveness of CPR. Eighty-six per cent of patients were willing to be routinely consulted by doctors about their own CPR status, but relatives were less enthusiastic about routine consultation. Patients' and relatives' (...) views about the appropriateness of CPR did not differ significantly. Seventeen percent of patients did not desire CPR. However, 64 per cent of patients were ultimately willing to follow their doctor's advice about the appropriateness of CPR. The conclusion reached is that mentally competent, elderly patients but not their relatives should be routinely consulted about their own desire for CPR in order to avoid resuscitating patients against their wishes. Further research is required to find out how patients would feel about resuscitation if they were terminally ill or chronically confused, and how carers would feel about resuscitating such patients. (shrink)

Objectives—To assess whether UK and US health care professionals share the views of medical ethicists about medical futility, withdrawing/withholding treatment, ordinary/extraordinary interventions, and the doctrine of double effectDesign, subjects and setting–A 138-item attitudinal questionnaire completed by 469 UK nurses studying the Open University course on “Death and Dying” was compared with a similar questionnaire administered to 759 US nurses and 687 US doctors taking the Hastings Center course on “Decisions near the End of Life”.Results–Practitioners accept the relevance of concepts widely (...) disparaged by bioethicists: double effect, medical futility, and the distinctions between heroic/ordinary interventions and withholding/ withdrawing treatment. Within the UK nurses' group a “rationalist” axis of respondents who describe themselves as having “no religion” are closer to the bioethics consensus on withholding and withdrawing treatment.Conclusions—Professionals' beliefs differ substantially from the recommendations of their professional bodies and from majority opinion in bioethics. Bioethicists should be cautious about assuming that their opinions will be readily accepted by practitioners. (shrink)

OBJECTIVES: To study the resuscitation preferences, choice of decision-maker, views on the seeking of patients' wishes and determinants of these of elderly hospital in-patients. DESIGN: Questionnaire administered on admission and prior to discharge. SETTING: Two acute geriatric medicine units (Southampton and Poole). PARTICIPANTS: Two hundred and fourteen consecutive consenting mentally competent patients admitted to hospital as emergencies. RESULTS: Resuscitation was wanted by 60%, particularly married and functionally independent patients and those who had not already considered it. Not wanted resuscitation was (...) associated with lack of social contacts. Sixty-seven per cent welcomed enquiry about their preferences and 78% wanted participation in decision, 43% as sole decision-maker. Wishing to choose oneself was associated with not wanting resuscitation, prior knowledge of it, and lack of a spouse. Patients' opinions remained stable during their admission. CONCLUSIONS: Discussion of resuscitation is practical on hospital admission without causing distress and the views expressed endure through the period of hospitalisation. Elderly patients' attitudes depend partly on personal health and social circumstances. This may assist doctors when patients are unable to participate themselves. (shrink)

Historically, patients have deferred to physicians′ judgments about appropriate medical care, thereby limiting patient participation in treatment decisions. In this model of medical decision making, physicians typically decided upon the treatment plan. Communication with patients focused on securing their cooperation in accepting a treatment decision that essentially had already been made.

The use of do not resuscitate (DNR) orders in Dutch hospitals was studied as part of a nationwide study on medical decisions concerning the end of life. DNR decisions are made in 6 per cent of all admissions, and 61 per cent of all in-hospital deaths were preceded by a DNR decision. We found that in only 14 per cent of the cases had the patients been involved in the DNR decision (32 per cent of competent patients). The concept of (...) futility is analysed as these findings are discussed. We conclude that determining the effectiveness of resuscitation is a medical judgement whereas determining the proportionality (burden/benefit ratio) of it requires a discussion between doctor and patient (or his or her surrogates). Since the respondents in the cases without patient involvement gave many reasons for their decision that went beyond determining effectiveness, we conclude that more patient involvement would have been desirable. (shrink)