Health: A matter of life and death and bleepers: Elderly patients can be left to die without their families being consulted. Liz Hunt reports

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Mabel Styche, 71, was sitting up in bed, drinking tea and chatting when her son and daughter left the hospital at five o'clock one morning. It had been an anxious four hours for them since Mrs Styche was rushed to a Birmingham hospital with chest pains and breathing problems, but now things seemed to be under control.

Barry and his sister, Kay, left their mother in what they believed were the capable hands of the doctors and nurses and went home to get some sleep. But as they slept a vital decision was being made about Mabel Styche: should she be allowed to live or die? Without consulting Mrs Styche or her family, a junior doctor had scrawled across her medical notes 'Not for 333' - an instruction to nursing staff that should she take a turn for the worse, no attempt should be made to restart her heart. The 'crash team' would not be called and Mrs Styche would not be resuscitated.

Last week the Government stated formally for the first time that it was acceptable for doctors to let the terminally ill, or those suffering from incurable illnesses, die by not intervening to treat new problems such as infections, which could kill them. It has also endorsed the use of high doses of painkilling drugs even if they hasten the patient's death. The statement, Government Response to the Report of the Select Committee on Medical Ethics, was widely welcomed by doctors and ethicists who see it as long-awaited acceptance of a principle that is an established part of medical practice - but which is rarely discussed outside the profession.

However, the statement failed to address another ethical issue, a practice equally long-established in hospitals and covert in many: the decision not to resuscitate certain patients, usually elderly, who have suffered a heart attack and who do not fall into the category of the terminally ill. If the patients are 'not for resuscitation', then a lethal code is written in their notes, incorporating the bleep number for the crash team, usually 222 or 333.

There have been several attempts to draw up guidelines for such cases, most recently in June 1993 in a joint draft by the Royal College of Nursing and the junior doctors committee of the British Medical Association. But there is no enforcement of national guidelines and most doctors are unaware of them. In addition, guidelines have focused on communication between doctors and nursing staff, rather than patients and their families. As a result, many hospitals do not have a coherent policy for dealing with these cases. According to one leading ethicist and adviser to the BMA's Medical Ethics Committee, if doctors fail to discuss it with patients or their families, then 'in a very real ethical sense they (the patients) are the victims of manslaughter'.

Professor John Harris, a lecturer in philosophy at Manchester University, adds: 'If the patient can be sustained, and it is reasonable to suppose they would want to be, then they are entitled to make that decision for themselves.'

Mabel Styche's condition did deteriorate and her children were woken by a telephone call later that morning asking them to return to the hospital as quickly as possible. They were too late. Their mother had died at 7am. Barry and Kay were devastated; she had seemed so much better. How could it all have gone wrong so quickly?

Barry was concerned that everything possible should have been done for his mother, and it continued to bother him. Then, some months later, he heard about the case of Ethel Cox, an 88-year-old woman admitted to another Birmingham hospital, whose family had discovered by chance that she had been designated 'not for resuscitation'. Her son had demanded that the direction be removed from her notes and complained to the NHS ombudsman. His mother recovered, was discharged from hospital and lived for another 18 months.

Mabel Styche was old, but her health was good enough to allow her to work three or four days each week in her immaculate garden. Her quality of life was excellent and Barry knew that his mother would want - and deserved - every chance of life.

Unfortunately, the doctors looking after Mrs Styche felt differently. ' 'Not for 333' was added to her notes just 15 minutes after we left,' Mr Styche says. 'No doctor saw her after 5.15am. When my mother started to have difficulties no attempt was made to resuscitate her. They basically let her die.' He and his sister are angry and bitter, believing that their mother had been 'written off, without a chance and in secret'.

They asked for a meeting with the consultant, who surprised them by reassuring the Styches that their mother had indeed been resuscitated but that the attempt had failed. Within weeks the consultant had written to them to say that he had been mistaken. The pain of her death and anger at the way in which she died was now compounded by the hospital's failure to give the family the real facts.

Barry and Kay Styche made a formal complaint to the West Midlands Regional Health Authority. Its report criticised the hospital for not consulting the Styches, and for allowing an inexperienced doctor to make a life-and-death decision on Mabel Styche's behalf.

'If they had tried and failed you'd accept that,' Barry says. 'The fact is a person we've never met went along to my mother and wrote a note 'not for 333' . . . and that denied my mother the chance of life.'

'Not for 222' will be shown on BBC 2 at 8pm on Thursday in the 'Taking Liberties' documentary series.

(Photograph omitted)