Email your comments

On raising your head above the parapet : DNR policies in residential homes

Dave
We were dismayed by the initial responses to the publication of our paper on DNR policy in residential homes, particularly the suggestion that it was ageist. We think that fortunately, most people must realise that this was partly due to sensationalism in reporting elsewhere and knee-jerk responses. Since then a more mature debate has begun. Dr Conroy, the brave first author of this piece who encouraged us all to put our head above the parapet, is continuing research into ethical matters (in his case, Advance Directives) and contributes to the ongoing debate that our paper has ignited.

Over time, the impression I have gained from colleagues, and others, commenting about our paper is that there is in some an unease and in some an abhorrence about the general issue of the use of CPR in people who are frail. Until recently geriatricians were fighting a hard battle against ageism and by this they meant that it is unacceptable for a 75 year old to be denied access to a coronary care unit and effective CPR on the grounds of age alone. Such outrages were taking place in the UK as recently as 5 years ago. Perhaps a by-product of this argument, but by no means can this be laid out our doors alone, there has passed into common (mis)understanding the idea that CPR is almost universally effective. Once this fallacy is held, of course it makes sense to insist that all frail people should be offered CPR, that withholding CPR is bad or ageist (if the frail person is old), and so on. The trouble with this fallacy is that it ends up with, to my mind, the unethical position that no-one should die until their ribs have been broken and this procedure has been applied. Withholding this is not ageist: not to recognise the special needs of the frail could, in itself, be called ageist – but throwing around the word “ageist” is rather like throwing around insults: it isn’t constructive. Many people do not understand how inhumane CPR can be. An anecdote that stays vividly in my mind is a chat I had with an excellent, fully trained senior SHO about CPR decisions in an educational session. At one point, bringing to mind the real life events that take place behind the curtains, she looked at me with welling tears in her eyes and said, “Dr Gladman, as an SHO I’ve been on dozens of cardiac arrests in the last few months. I have never seen anyone survive yet. I feel sick with what I am asked to do….I didn’t go into medicine to do this.” She was not simply reflecting her personal distaste, but the sense that this was actively contrary to the humane purpose of a civilised health care system. I haven’t seen this on TV medi-dramas (mind you, I don’t watch them).

It is all the more a problem when one looks at the state of medical care in the care home sector, where investment in CPR training and equipment surely has to be balanced against investment in other areas such as preventing institutional abuse, better medicine management, improved symptom control, sensible disability management, good terminal care, and effort to improve quality of life as opposed to warehousing. We know these problems exist and people suffer from them. There must be a debate about where our priorities lie, and whether our policies prevent us from responding to priorities properly. This is not merely an arm chair debate: I have been contacted by people who have been faced with implementing CPR policies in care homes and the current policy climate in this area gives them little scope to act in a way that seems reasonable, given their limited resources and the huge range of problems facing them. They found our article a help in supporting the case for something other than mass implementation of a policy that was more suited to a setting, such as a hospital, where going home is the intended outcome as opposed to care homes where death is the usual outcome.

Exactly how the care home sector and the policy makers will respond must be through a process of debate in which our paper is but one part. We are glad that at least our paper has contributed to this debate. We also hope that, over time, our paper will be part of a process that dispels the publicly (and sometimes professionally) held myths about the real nature and effectiveness of CPR, and hence that debates about CPR policy will be more rational.

John Gladman