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EDITOR'S CHOICE: Fiona Godlee Do not resuscitate, or fly BMJ 2006; 332: 0-f [Full text]

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Cardiac Arrest Is The Wrong Diagnosis

John J Turner   (26 February 2006)

Cardiac Arrest Is The Wrong Diagnosis 26 February 2006
John J Turner, Consultant Physician University Hospital Aintree Liverpool L9 7AL Send response to journal: Re: Cardiac Arrest Is The Wrong Diagnosis	Editor A high proportion of Cardiac Arrest calls in frail older patients with advanced disease including severe chronic obstructive airways disease, cardiac failure, dementia and metastatic disease results in no useful outcome. It inflicts an unnecessary procedure in situations where a natural death should be as dignified and peaceful as possible. The excellent prospective study from Helen Fidler et al in today's BMJ reveals what physicians already know that most acute medical admissions of frail older patients cannot meaningfully participate in discussions about Do Not Attempt Resuscitation [DNAR]. In the same edition the thoughtful comment from Simon Conroy, Tony Luxton et al with its poignant deathbed scene should help to counter over enthusiasm for cardio-pulmonary resuscitation [CPR] in continuing care settings. The national guidelines framework insists on a level of communication with patients and their families which inhibits good clinical decision making and makes it difficult to write a DNAR decision even when this is clearly in the best interests of the patient. Many relatives hold a romanticised Holby City style image of CPR which leads on to stark discussions about choosing life or death, creating unnecessary tensions and anxieties for patients and families. We should more clearly recognise the concept that the final event will be a perfectly natural death that should not wrongly be characterised as a 'cardiac arrest'. We now have CPR as the default position regardless of appropriateness. This results in the paradoxical position that CPR which by its nature is a rather aggressive and violent assault is pursued in many patients because we are required to seek consent not to do it even when the medical team know that this is going to be a futile procedure. The result is often a perfunctory and brief initiation of CPR by the arrest team who do not know the patient discontinuing when the clinical facts are elicited from the case records. The twin pressures of potential allegations of Ageism or Paternalism are very real and may result in relatives wrongly perceiving a denial of treatment which undermines good professional advice and decision making. The national guidelines framework comes from the Ethics Committee of The BMA which is reasonably comprised of a large number of lay experts in Law and Bioethics but unreasonably does not include a single representative from any adult medical specialty. DNAR policies have a very poor compliance record throughout the UK because they do not command the respect of clinicians and are operationally unsound. A policy shift is needed to improve the position and make it easier for clinicians to make appropriate DNAR decisions acting in the best interests of patients. Competing interests: Member of Aintree Hospitals NHS Trust DNAR guidelines group