Do not resuscitate decisions: flogging dead horses or a dignified death?

An elderly woman died in hospital and her family, investigating her care, found “NFR” (not for resuscitation) on her notes. There had been no discussion about this with either her or them. An independent review upheld the family's complaints and noted, “It was hard to avoid the conclusion that the treatment plan . . . was to do little more than allow the patient's life to ebb away.” This is just one of a dossier of over 50 case histories assembled by Age Concern England that have been publicised in newspapers in the United Kingdom, and it is part of the charity's wider campaign to eradicate ageism in the health service.¹,²

Last year the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing jointly said that do not resuscitate orders could be considered only after discussion with the patient or others close to the patient. Age Concern's dossier is evidence this guideline is being flouted.

Resuscitation after a cardiopulmonary arrest is effective in only one in five patients.³ Although it may be appropriate to withhold resuscitation when a patient is dying, failure to involve patients in decisions on do not resuscitate orders negates their autonomy. It is most unfair for age to be used as a criterion to withhold cardiopulmonary resuscitation. Most patients and relatives consider that discussions about death and do not resuscitate orders are essential aspects of planning their care.⁴ It is doctors and nurses who find such discussions painful.

Do not resuscitate orders are increasingly used and have greater implications than merely not calling the resuscitation team.⁵ The do not resuscitate orders in Age Concern's dossier came to light when complaints about quality of care were investigated. So is there evidence that do not resuscitate orders that are made without patients' or relatives' consent are a barometer for unethical, inadequate care?

Over two thirds of patients with do not resuscitate orders are not involved in making these decisions.⁶ These decisions not to resuscitate, when reviewed, are poorly understood by patients; information given is not recalled; and viewpoints may change.⁴,⁷ After adjustment for disease severity, prognostic factors, age and other covariates, patients given these orders are more than 30 times more likely to die, suggesting that do not resuscitate orders may reduce quality of care.⁸ Do not resuscitate orders are more commonly used for older people and, in the United States, for black people, alcohol misusers, non-English speakers, and people infected with human immunodeficiency virus—suggesting that doctors have stereotypes of who is not worth saving.⁵,⁹

The failure of health professionals to follow guidance for the use of do not resuscitate orders is part of a wider concern over ageism in the NHS. Ageism in cardiology is well documented and reflects ageism in society.¹⁰ Although the Royal College of Physicians acknowledged in 1991 that chronological age is not as important as disease severity and comorbidity in determining ability to benefit from treatment, this principle is still not applied in practice.¹¹ Other specialities, including primary care, are not innocent of age discrimination. A survey by Age Concern found that 1 in 20 people aged over 65 had been refused treatment by the NHS, and 1 in 10 of those aged 50 or older felt that the health service treated them differently because of their age.²

What more can be done? The usual hopeless solution—audit, training and education, more research—are even less able to deal with ageism. Our attempts over the past three decades to produce humane doctors and nurses, capable of responding to patients' needs regardless of age, have not been rewarded.¹² Medical students still rejoice in their stereotypes of “geriatric crumble” and “GOMER” (get out of my emergency room) patients. Leadership, vision, and resources are needed to deal with marginalised people in our society.¹³ The first steps in making progress is to acknowledge—at the highest level—that stereotyping on the basis of age exists and is unjust.¹⁴ Eradicating ageism in the NHS will almost certainly require legislation.