Cardiopulmonary resuscitation in continuing care settings
- or 'on the art of raising your head above the parapet'

It is a relatively rare thing for older people’s care to appear on the national media’s radar, but readers may be aware of the furore created by Simon Conroy, et al’s paper: “Cardiopulmonary resuscitation in continuing care settings: time for a rethink?”, published in the BMJ Volume 332 (25 February).

In brief, Simon, Tony Luxton, Robert Dingwall, Rowan Harwood and John Gladman call for resuscitation policies in care homes and community hospitals to be reviewed in view of the fact that, “In acute hospitals, the overall rate of survival to discharge is about 14% and up to half of survivors will suffer functional or neurological impairment. In public places, typical survival rates are 5-10% with over two-thirds of survivors suffering neurological problems. In care homes and community hospitals, data suggest survival rates of between 0-6%.”[1]

“The costs associated with resuscitation can be argued to be largely at the level of the institution. For example, if one person in a care home or hospital is to be provided with cardiopulmonary resuscitation, all staff require training and the appropriate resources need to be funded. Given the likely low chance of success, it may be that the institution should not offer resuscitation at all. Resources saved by not spending time in training and the subsequent discussions could be better used in improving the quality of care…

Of course, some institutions (care homes or community hospitals) may decide to continue to provide resuscitation. Such institutions might allow healthcare professionals to make an informed decision, albeit uncertain, on the likelihood of success of cardiopulmonary resuscitation. If the chances of success were low (perhaps less than 2% or 5%), a do not resuscitate order could be issued without further discussion, unless the patient or resident requested it. In this case the discussion would largely be an explanation of “why not,” rather than a negotiation about “whether.” If the chances of success were thought to be higher, resuscitation would be attempted unless the patient had indicated that he or she did not want it after discussions initiated by either the healthcare professional or the patient. We believe the current guidelines should be reviewed. Future advice should have more regard to the needs of non-acute settings.”[2]

While some of the media’s response was commendably measured, the Daily Mail’s headline cried, “Let old folk in care die”. Commenting on the media’s interpretation of the paper, Jonathan Ellis of Help the Aged is quoted as saying that proposals were ‘unethical’, an attack on the rights of the elderly and “The suggestion to withdraw resuscitation from care homes, whom older people are the single biggest group of users, smacks loud and clear of ageism. It is unethical to propose that there should be blanket removal of resuscitation protocols from care homes simply because they might not work. These same arguments would not be used if the discussion was about other patient groups. Decisions about resuscitation should be taken wherever possible in partnership with the individual patient and their family. Older patients should not have their right to decide taken away from them.”

Bringing a measure of balance to the argument was Dr Rowan Harwood’s reply in the “Have your say” section of the Daily Mail:

“I am a Geriatrician and I fight ageism every working day. I firmly believe in modern, effective, medical care for all ages.

What is involved here is not denying care. It is not letting people die. Or euthanasia. It is not about denying appropriate preventative, therapeutic or palliative medical or nursing care. Or about denying information, respect, dignity or choice. It is about what you do when someone’s heart has stopped.

If you have just had a heart attack (blocked artery damaging the heart muscle), which is when your heart is most likely to stop, then you have a reasonable chance of being revived by electric shock treatment to the heart, especially if you are in a bed on a coronary care unit. At any age. No question.

If you are a resident in a care home, you are there because of multiple medical problems and disabilities. Attempts to restart a stopped heart do not work. This is not discrimination but simply a recognition of what works and what does not.”

The BGS was, understandably, called to give its position on the paper but this it clearly could not do at such short notice. Whereas the BGS membership may be unanimous in its views on issues such as ageism and the treatment of incontinence, we know from the reaction to Lord Joffe’s Bill on Assisted dying for the terminally ill that there will be too many opinions among our members to be able to present the media with the BGS’s nicely parcelled “position” on Simon et al’s proposals, as Help the Aged were prepared to do.
The matter of DNR policies, including DNR in the wider context raised by Simon and his co-researchers, will be the subject of discussion at the BGS Policy Committee with a view to adding to our compendium of policy. Readers’ views are invited.

David Beaumont
Jackie Morris