The Department of Health last night gave cautious approval to new guidelines adopted by Addenbrooke's Hospital in Cambridge, to offer those patients who are unlikely to be well enough to be discharged the chance to refuse resuscitation in advance of a cardiac arrest.
The guidance has been introduced to end confusion and dilemmas often experienced by medical and nursing staff when someone who does not have long to live suffers a heart attack.
'Do not resuscitate' orders are sometimes verbal rather than written in the patient's notes, and the extent of regular consultation with a patient or close relative about their wishes in these circumstances varies widely, even within a hospital.
A study published in the British Medical Journal this week found communication between staff was often inadequate to ensure that doctors' instructions were implemented. In 15 per cent of nurses' decisions surveyed at five acute medical wards, there were misapprehensions that 'do not resuscitate' orders applied to particular patients. Moreover, nearly one in five nurses believed that attempts were not to be made to save a patient, even where there was no supporting documentary evidence.
The Addenbrooke's guidelines were drawn up by a committee, chaired by Dr Gilbert Park, a consultant anaesthetist, which examined different situations where resuscitation decisions arose. It found that only 15 per cent of terminally ill patients survive to be discharged after cardio-pulmonary resuscitation. 'The decision not to resuscitate will be made by doctors, patients and their relatives. But it won't be imposed on anybody because the patient's view remains paramount,' Dr Park said.
Dr Stuart Horner, chairman of the British Medical Association's ethics committee, who was himself resuscitated after a heart attack three years ago, welcomed the Addenbrooke's move. 'Doctors are perhaps too hesitant to talk to elderly patients about issues affecting their life and death. I don't think asking these questions would destroy a patient's confidence in the doctor. They would welcome more openness,' he said.
However, Counsel and Care, an advice group for older people and carers, expressed caution. Jef Smith, its general manager, said: 'Elderly people are very vulnerable and do not always speak their thoughts frankly. They are particularly amenable to pressure from professionals who might be inclined to put words in their mouths. Such patients should have routine access to independent advocates to represent their interests.'