To what extent should older patients be included in decisions regarding their resuscitation status?

Abstract

As medical technology continues to advance and we develop the expertise to keep people alive in states undreamt of even 20 years ago, there is increasing interest in the ethics of providing, or declining to provide, life-sustaining treatment. One such issue, highly contentious in clinical practice as well as in the media (and, through them, the public), is the use of do-not-attempt-resuscitation orders. The main group of patients affected by these orders is older people. This article explores some of the arguments regarding who should make the decision to implement such an order, with particular reference to older people and the unique issues they face in relation to resuscitation. The author concludes by arguing that official guidelines, while representing an ideal, are not easily applied in a typical acute setting where decisions regarding resuscitation are most commonly made, and makes suggestions as to how they may be implemented more successfully.

Barriers to involving older people in their resuscitation decisions: the primary-secondary care mismatch highlights the potential role of general practitioners

“…Older people may be more ready to accept their mortality (22) and therefore welcome initiation of the topic by healthcare professionals(23). These could be explored in primary care by GPs or trained specialist nurses who have a more long‐term relationship with patients(2) and could discuss advanced directives over multiple visits(24).…”

“…There may be opposing views of medical opinion (futility) and patients' (and relatives') unrealistic expectations about success of CPR (8). The mental capacity or competency of the patient due to delirium or dementia is also an issue (2).…”

“…If resuscitation is likely to be futile, or is against patient’s wishes, then it is a good clinical practice to consider a ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) order. DNACPR orders are made more frequently for older people(1)(2). With two‐thirds of hospital beds currently occupied by older people, and numbers of people aged 85 years and over predicted to increase by approximately 66% from years 2002 to 2022 (3,) all doctors are more likely to be increasingly involved in CPR decisions in the future.…”

“…A point of contention from this guidance relates to patient involvement in resuscitation decisions. Studies repeatedly find that doctors are less likely to involve patients(5–8), although they frequently discuss these decisions with relatives(2,8,9). Reasons for this paradox include feeling uncomfortable with end‐of‐life discussions(1,8), fear that it may cause undue distress to the patient or be inappropriate at that time (6) or take away hope.…”

“…A point of contention from this guidance relates to patient involvement in resuscitation decisions. Studies repeatedly find that doctors are less likely to involve patients (5)(6)(7)(8), although they frequently discuss these decisions with relatives (2,8,9). Reasons for this paradox include feeling uncomfortable with S U M M A R Y Background: 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) orders are made frequently for older people in hospital.…”