The bioethical issues confronting the Jewish chaplain in a long-term care facility are critical, particularly as life-support systems become more sophisticated and advance directives become more commonplace. May an elderly competent patient refuse CPR in advance if it is perceived as a life-prolonging measure? May a physician withhold CPR or artificial nutrition and hydration (which some view as basic care and not as therapeutic intervention) from terminal patients with irreversible illnesses? In this study of Jewish ethics relating to these issues, (...) the author carefully examines the moral implications and legal precedents in the literature. Jewish ethics, affirming a 'sanctity of life' position, suggest that while an elderly person may direct in advance that CPR not be administered in most instances, in the absence of a DNR (Do Not Resuscitate) order, CPR must be performed. In reference to 'tube-feeding', while there is some debate about whether elderly patients may refuse the initiation of 'tube-feeding', there is a consensus that once initiated, it may not be withdrawn. (shrink)

The author reviews and continues the debate initiated by her recent paper in this journal. The paper was critical of certain aspects of palliative medicine, and caused Ashby and Stoffell to modify the framework they proposed in 1991. It now takes account of the need for artificial hydration to satisfy thirst, or other symptoms due to lack of fluid intake in the terminally ill. There is also a more positive attitude to the emotional needs and ethical views of the patient's (...) family and care-givers. However, clinical concerns about the general reluctance to use artificial hydration in terminal care remain, and doubts persist about the ethical and legal arguments used by some palliative medicine specialists and others, to justify their approach. Published contributions to the debate to date, in professional journals, are reviewed. Key statements relating to the care of sedated terminally ill patients are discussed, and where necessary criticised. (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)