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Response to: increasing use of DNR orders in the elderly worldwide: whose choice is it
  1. A D Lawson
  1. Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK; a.lawsonic.ac.uk

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    I read Dr Cherniack’s article regarding do not resuscitate (DNR) orders with interest.1 One of the problems with DNR orders is the patients’ assumption that if there is no DNR order they will survive resuscitative efforts. This of course is far from the truth. In my hospital these orders have been modified to “do not attempt to resuscitate” orders. One cannot be truly autonomous without being informed. Long term survival, as measured only by being alive, following inhouse cardiac arrest, is about 15% over all age groups.2 In sick elderly patients over 70 years of age who survive a cardiac arrest, the subsequent hospital mortality approaches 100%. This fact, and concerns about harm, influence physicians’ attitudes, particularly where the general public have wildly unrealistic expectations of the results of resuscitation, as mentioned in the paper by Godkin and Toth.3 Significant neurological disability is common following cardiac arrest: up to 50% of the survivors of cardiopulmonary resuscitation (CPR) in one study.4 Medical staff are clearly aware of the hazards of resuscitation, doctors have been shown to be highly selective as to when they would wish resuscitation to take place for themselves,5 and in one group of emergency workers few were found who were willing to undergo full resuscitation as “currently practised”.6 While age as such is not necessarily a predictor of poor outcome of intensive care7 advancing age is associated with an increasing incidence of systemic diseases, which do predict poor outcomes following arrest.8,9

    As a society we seem to strive to prevent death, pursuing the next line of treatment at any cost and this struggle against disease has been described as “trench warfare against death”.10 Patients and their relatives expect physicians, as fiduciary agents, to do everything in their power to help cure them and save their lives, but there comes a point where not doing something is the better thing to do. Physicians tend to endeavour to do all that they can, as Morreim puts it “embracing a technological imperative that favours action over inaction”.11 The fact that we would not wish it upon ourselves, however, says a great deal about what we think of resuscitation in the sick elderly patient. Dr Cherniack comments that when information about CPR is presented more negatively then fewer elderly will choose it. He seems to imply that one could be more positive if only one wanted to. I fail to see how one can be positive about brain damage, a stay on the intensive care unit (ICU), and the near certainty of death. In certain circumstances CPR is simply harmful. Outcome statistics and the high incidence of morbidity have led one group to conclude that “treating our elders this way is maleficent”.12

    It is a moot point whether there is any moral obligation to discuss treatment options that are not really treatment options, particularly where the potential to do harm far outweighs any benefit. Survivors of resuscitation are transferred to ICUs. Patients who have spent time on ICUs report nightmares, depression, and high levels of distress, and up to 40% have recollection of pain.13,14 Is this a beneficent act if survival is not a realistic possibility? I think not, but of course a vitalist would disagree. By all means we should ensure that we respect patients’ autonomy by asking their preferences, but we have to be totally frank about outcomes. Not to be so would be to infringe patient’s autonomy as much as disregarding their preferences.

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