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.
Statistics from Altmetric.com
Cardiopulmonary resuscitation (CPR) as it is commonly understood was first properly developed for human use in the 1960s.1 At that time, it was used primarily in younger, fitter patients who had a sudden cardiac event, where it still enjoys relatively high success rates. Because of this success, its use has been extended beyond these patients, and is now commonly performed on people for whom it is often futile, such as older, frail patients with extensive comorbidity.
Medical authorities have realised that it is not always appropriate to attempt CPR: in some cases, cardiac arrest represents the natural end of a life, and resuscitation in this setting may be unwise.2 This is often considered to be the case, for example, in those who are terminally ill and recognised to be in the final stages of their illness. For that reason, they suggest that a do-not-attempt-resuscitation (DNAR) order may be made in certain circumstances. These include situations in which CPR would be unlikely to restart the heart, where restarting the heart has no benefit and where the expected benefit is outweighed by the burdens.
These standards do, however, demand that patients are involved in any decisions to be made about their resuscitation status if they are competent.2 Despite this, it is often the case in practice that such discussions do not routinely occur,3 4 even where specific guidelines in hospitals make them mandatory.5
There is evidence to suggest that many patients would welcome inclusion in the discussion of their resuscitation status. A study by Morgan and colleagues6 interviewed 100 alert hospital inpatients and found that 98% of them were happy to be asked about the topic. This is in contrast to some authors who have suggested that involving patients in such discussions could potentially make them uneasy and anxious, spoiling what may be the last few days or weeks of their life.7 There appears to be little evidence to support this view, with the only study that showed this having been performed in terminally ill teenagers.8 It has been proposed by some6 9 that older people would be more ready to accept their mortality than younger patients, a viewpoint backed up by developmental psychologists such as Erikson and Butler, who see old age as a time of reflection on life and preparation for death (see Walker et al).10
Nevertheless, decisions regarding resuscitation are often taken during periods of acute illness11 when the patient may already be distressed. Some older people have indicated that a discussion under these circumstances may increase their anxiety.9 In addition, acute illness often leads to confusion in older patients,12 many of whom also have dementia,13 and so their capacity to be involved in the decision may be called into question.
This being the case, many families of patients assume that it is their place to make a decision regarding resuscitation,2 and studies have shown that doctors are more likely to discuss this subject with the family than with the patient.6 This is despite the fact that, until April of 2007, families had no right to make decisions on behalf of their relatives.14 Recently, the UK’s Mental Capacity Act 2005 has allowed people specifically nominated by the patient (which may include family members) to make these decisions.15 However, it is unlikely, especially at present, that many older people will have nominated such a person under the act, and so this remains largely a moot point. Guidelines suggest that family members should be consulted in resuscitation decisions regarding incompetent patients, but this is in order to ascertain any views held by the previously competent patient, not the opinion of their relatives.2 Despite this, the author has been involved in a number of situations where relatives of patients have been allowed to make the final decision for doctors, and anecdotal evidence seems to suggest that this is not uncommon practice.16
When Morgan and colleagues compared the preferences of older people and their relatives on resuscitation, they found wide differences in opinion. Of the patients who thought that they should be consulted on discussions regarding resuscitation, almost half thought the final decision should be theirs alone, whereas nearly half of their relatives thought that it should be their decision, not the patient’s.6 There has been little investigation as to whether relatives are able to accurately predict their relative’s preference for resuscitation; however, Morgan and colleagues found that older patients and their relatives disagreed significantly in hypothetical cases presented to them.6
With so many older patients wanting, but perhaps unable, to make a decision, and little evidence that the family can effectively advocate for a patient, it may seem logical that the final decision should be left to the physician. However, research has also shown that there is widespread discrepancy between the views of doctors and their patients on the utility of CPR.6 In particular, doctors may be likely to consider the use of a DNAR order in cases where they judge that there is little benefit with regard to quality of life in performing CPR; however, such value judgements may be at odds with those of their patients. For example, one study shows that 20% of patients wanted CPR even if they were terminally ill or permanently unconscious,17 two situations in which doctors are likely to be of the opposite opinion. There may be a place here for nurses, who generally spend more time with hospitalised patients and get to know them better, and perhaps are better able to predict their views on resuscitation, to help in the decision-making process, in conjunction with doctors.
Some authors have suggested that doctors may be justified in making the decision alone if a patient is incpable or is not predicted to survive a CPR attempt.18 However, research has shown that healthcare professionals are markedly inept at identifying either of these circumstances. One study found that 23% of patients who were found to be competent to make decisions relating to CPR by research staff had been judged incompetent to do so by their own physicians.19 This would mean that if the suggestion of Stewart and colleagues18 were to become policy, nearly a quarter of patients would have their decision-making powers removed from them unnecessarily. The Mental Capacity Act 2005 addresses the situation by defining a clear test of mental capacity, and recommending that even incompetent patients should be involved as much as possible in decisions.15 However, while it provides guidance, it cannot be enforced in the case of instituting a DNAR order, as consent law applies only to decisions to treat, rather than to decisions not to treat, which do not require patient consent.1 A further study found that physicians were unable to predict likely survivors of CPR and that a similar level of accuracy could be expected of a coin toss.20 Therefore, if decisions were made by doctors alone based on their opinion of the likely success of CPR, many patients would face inappropriate resuscitation whereas others would have inappropriate DNAR orders in place.
Furthermore, a doctor’s or nurse’s opinion of what is an acceptable threshold of likely survival at which to withhold CPR may be very different from the patient’s. The ethical principle of autonomy can be taken to suggest that patients themselves are best placed to make a decision as to when the risk of harmful effects of an intervention outweighs its advantages. The media, in common with many patient groups, have argued that individual patients should therefore be the main decision-makers with regard to CPR. One paper describes a law in the US state of New York that makes patient agreement to DNAR orders mandatory, and thus puts patients as “for CPR” by default.21 Some authors9 argue that this leads to more resuscitation and that this is often harmful. If a patient has not made a decision to implement a DNAR decision and then becomes incompetent because of an illness, healthcare professionals and relatives are powerless to withhold resuscitation, even when this may clearly be in the best interests of the patient.
While it may be ethically desirable to incorporate patient autonomy in decision-making, ethicists commonly describe three other principles of medical ethics: justice, beneficence, and non-maleficence.22 In particular, the desire for non-maleficence may suggest that in some circumstances CPR should not be provided. The technique of CPR is violent and undignified, and if used inappropriately is considered by many to be injurious, disrupting what would otherwise have been a peaceful death.2 There is a wealth of evidence to suggest that older people have worse outcomes after resuscitation than their younger counterparts. A comprehensive 10-year study of outcomes after in-hospital cardiac arrest in a UK general hospital showed that those who were aged under 50 years had a 28.2% survival rate at 24 h, compared with only 9.6% for those aged over 80.23 This effect of age has been found by other researchers looking at cardiac arrest both in 24 and out25 of hospital. However, some researchers have found that age in itself is not an indicator of prognosis, instead suggesting that comorbidity (which increases with age) is a more likely factor.1 Those older people admitted to hospital with a single medical complaint and who are otherwise fit and well may have as good a chance of survival after CPR as their younger counterparts. It would therefore be unethical for individual healthcare professionals or institutions to have a blanket policy on resuscitation based on age, removing choice from an individual patient who may be an exception to the rule.
If CPR is successful, harm may also have been caused if severe cognitive impairment has occurred as a result of hypoxia during the peri-arrest period, or if there has been significant trauma to the chest, both of which are particularly likely in older patients. One study found that older patients were likely to have a cardiac arrest caused by pulseless electrical activity,24 which is not responsive to defibrillation and may therefore lead to a prolonged period of resuscitation, increasing the likelihood of neurological impairment in the unlikely event that the patient survives. In addition, osteoporosis and other degenerative bone disorders are more likely in older patients,26 who would therefore be more likely to sustain rib fractures during chest compression, with the associated complications of pain, pneumothorax and internal bleeding.
There is an argument that for these patients who may be harmed by CPR, resuscitation should not be attempted,2 and many doctors and nurses faced with this kind of patient may be inclined to withhold resuscitation. Healthcare professionals cannot be forced to offer treatment that they know to be harmful or futile,2 14 and life-sustaining treatment is perhaps the only area of care where they are routinely faced with making a decision to do so.4 When advising patients, healthcare professionals would not normally propose treatments with little benefit, and indeed life-sustaining treatment is the only area in which they are routinely faced with making a decision to do so. Indeed, the Nursing & Midwifery Council’s code of conduct27 makes it clear that nurses must act in the best interests of patients, which are normally not met by offering false hope in life-limiting situations. However, decisions regarding life-sustaining treatment such as CPR are very emotive. In this case, the principle of non-maleficence clashes with that of autonomy, and it can be difficult to know where to draw the line. Official guidelines2 appear to come down on the side of autonomy, suggesting that patients may be the best judges of their best interests, whereas in practice, healthcare professionals appear to lean towards non-maleficence and beneficence, sometimes to the exclusion of any patient choice.4
A similar dilemma is faced when considering the effect of the ethical consideration of justice on decision-making. Justice involves finding the right solution for society at large22 and could be said to include the effects of the decision on the family, the healthcare professionals involved and the institution.
Conroy and colleagues suggested that because of poor success rates, continuing-care settings such as nursing homes should opt not to provide CPR to any patients.28 They analysed the results of several studies and concluded that for a typical 50-bedded nursing home, a cardiac arrest requiring treatment would be a very rare event and that they might expect to initiate just one successful resuscitation attempt every 8 years. Even in the USA, where resuscitation in nursing homes is far more developed than in the UK, success rates are very low.28 Cobbe and colleagues showed that survival rates from out-of-hospital cardiac arrest in the UK are very low in older people,25 and presumably these would be even lower in nursing home residents, who are likely to have extensive comorbidity.
As the overwhelming majority of service users in nursing homes are older people, this is an issue particularly relevant in discussion of older people. Standard one of The national service framework for older people (NSFOP)29 deals specifically with the issue of age discrimination in older people, stating that age-based policies regarding treatment should be banned within the UK National Health Service and all other government-controlled health and social care services. A blanket decision not to resuscitate residents of a nursing home would surely be a de facto case of age discrimination under this definition. The NSFOP indicates that each individual case should be considered on its own merits and that blanket age-related criteria to treat are unfair, and it specifically mentions resuscitation policies in relation to this.29
However, the argument of Conroy and colleagues does have some valid points. Given the likelihood of a successful outcome, there is an argument relating to ethical justice. Training nursing home staff in resuscitation to a sufficient level for them to be effective in an emergency, and providing them with equipment, is likely to cost a great deal of money. The money comes out of the home’s budget, which is paid for directly by residents, and indirectly by taxpayers, all of whom demand value for their money. Conroy and colleagues estimate that the cost would be £28 000 per life saved.28 This money, they argue, could be more usefully spent on improving the quality of life for these older people, which would represent better value for taxpayers’ and residents’ money.
Conroy and colleagues do indicate that if such a policy should be instituted, potential service users should still be consulted before agreeing to move into the home.28 However, for the policy to work, it would have to apply to all residents of a particular home, and so while older people may be consulted, if they did not like the policy they would be unable to move in. If such a policy became widespread practice in this sector of healthcare, in effect older people may be denied any choice whatsoever: discussions may still be carried out, but older peoples’ wishes would have no bearing on the outcome.
The issue of resuscitation is emotive and contentious. Obviously, current practice does not reflect professional or ethical guidelines, but the extent to which this is a desirable situation is not clear. Older people interviewed both prospectively and retrospectively seem to indicate that it is not. Doctors and nurses who routinely face these situations believe that taking decisions alone or in conjunction with family, while excluding the patient, is acceptable.
There is conflict between several ethical principles. Respect for autonomy requires that patients are allowed to make their own decision on resuscitation, having weighed up the facts. The principle of beneficence requires healthcare professionals to act in the best interests of the patient, which are usually far from clear, especially during periods of critical illness when patients themselves cannot be consulted and the responses of those close to the patient may be emotionally charged rather than objective. Non-maleficence prohibits doctors and nurses from doing harm, which CPR certainly has the potential for; however, a patient’s autonomy or best interests may sometimes dictate that this should not be a factor. Justice means that sometimes, for the greater good, it may be appropriate for decisions to be taken in a wider context than solely the patient’s own best interests.
While the benefits and otherwise of CPR on an institutional level in relation to older people are not easily settled, decisions relating to the patient as an individual can be improved. Currently, decisions seem to be made only when the patient has already reached crisis point and are, for reasons of competency and avoiding distress, unlikely to be consulted. However, cardiac arrest is not an entirely unanticipated event in older people. Old age is the natural end of life for everybody, and at the end of all life comes a period of (potentially) reversible cardiac arrest.
It is clear that no one party is best placed to make a decision regarding resuscitation. Official guidelines2 have therefore suggested that all should be involved in the decision-making process; however, their recommendation that senior doctors should make the final decision appears in practice to have skewed the process in favour of the medical agenda rather than the patient’s agenda. One of the reasons often cited for this is that patients are often incapacitated or highly distressed at the time when decisions need to be made.
Given the inevitability of the situation, older people should be consulted at a much earlier opportunity, as this would allow their views to be ascertained in advance of their becoming incapacitated. An “advance decision” under the Mental Capacity Act 2005 would allow those patients who would prefer to forgo CPR to have this enforced legally.15 While nobody can insist on treatment, those who do wish to receive CPR might consider granting lasting power of attorney under the same act to a relative or friend who is aware of their wishes,15 or drawing up a statement of values and beliefs,30 both of which could serve to guide healthcare professionals in the event of incapacity.
Ideally, these options could be explored by primary care professionals such as general practitioners and district nurses, who come to know their patients over a period of time, in a relationship of mutual trust and respect. This information could then be shared by means of the NHS information technology programme, which aims to connect patients’ records from a number of providers and make them instantly available to others,31 in this case a hospital’s emergency department. Decision-making in advance is perhaps the only way in which older people can truly have their say, and obeys the spirit as well as the letter of professional, legal and ethical guidelines.
The author acknowledges the help of Dr Toni Bunnell (lecturer, Department of Health Professional Studies, University of Hull) in reading the manuscript and making suggestions.
Competing interests: None.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.