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The British Geriatrics Society
The British Geriatrics Society (BGS) is the only professional association, in the United Kingdom , for doctors practising geriatric medicine. The 2,200 members worldwide are consultants in geriatric medicine, the psychiatry of old age, public health medicine, general practitioners, allied health professionals, and scientists engaged in the research of age-related disease. The Society offers specialist medical expertise in the whole range of health care needs of older people, from acute hospital care to high quality long-term care in the community.

Geriatric Medicine
Geriatric Medicine (Geriatrics) is that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness of older people. Their high morbidity rates, different patterns of disease presentation, slower response to treatment and requirements for social support, call for special medical skills. The purpose is to restore an ill and disabled person to a level of maximum ability and, wherever possible, return the person to an independent life at home.

The Society is delighted to be given the opportunity to review this draft and would comment as follows:

1. The recent joint statement is a welcome revision of the guidance written by the same bodies in 2001. The earlier guidance followed much publicity on the whole issue of DNAR decision-making, and emphasised the importance of transparent decisions involving patients and families as much as possible. However, this advice led many hospitals to believe firstly that the issue of CPR should be raised routinely with all admissions, and that secondly a DNAR decision by the medical team must be discussed with the patient if possible, regardless of the context. This has run the danger of upsetting some patients, while in some hospitals there has been in fact a reduction in the placement of DNAR orders because of difficulty in achieving the required level of discussion. In fact the 2001 guidance did not advise routine discussion in every case, but did emphasise that decisions should follow a sensitive exploration of the patient’s wishes, unless the patient has given a clear indication that they do not wish to discuss the issue.
2. The new document is almost twice as long, but far more helpful, relating better to the real circumstances encountered in clinical practice. The tone is quite different, and will encourage greater use of appropriate DNAR decisions. There is a new section covering medical decisions not to attempt CPR, and how this should be communicated. While this approach receives some mention in 2005 Resuscitation Council guidelines, it was not included in the 2001 joint statement. It is made quite plain that it is not necessary to initiate discussion regarding CPR either if an arrest is seen as unlikely, or if CPR would clearly be unsuccessful on medical grounds. There is also welcome advice that where a formal decision has not yet been made, and yet it is clear that a patient is in their final stages of life, it is acceptable not to attempt CPR. These clear emphases will be very welcome to Hospital Trusts.
3. The distinction is now made clearly between the scenario where CPR is medically very unlikely to be successful and the more uncertain scenario where resuscitation might be successful, but impose burdens, and not be welcomed by the patient. The 2001 guidance implied that one might only decide the burden exceeded the potential benefit where “patients with such profound disability that they have or minimal levels of awareness, or where they suffer unmanageable pain…”. The 2007 adopts a much more reasonable tone, based around the facts of the relatively low success rate even in optimal situations. This will encourage frank discussions and DNAR decisions with patients struggling with end-organ failure who did not quite fit the descriptions of the earlier document.
4. There can be great difficulty when there is lack of agreement on CPR decisions. The 2007 document again provides excellent advice within each of the main scenarios. It is helpful to see confirmation that with CPR as other treatments, doctors are not forced to offer treatments which they believe will be ineffective.
5. Another new section is on advance care planning. This is welcomed, as discussions about prognosis and disease progression are clearly the correct context to understand patient’s wishes for future care, and this can merge naturally with discussing the dying process. The distinction between a valid advanced directive and notification of patient’s views, currently or previously expressed, is also helpful.
6. The 2007 document also includes many references to the 2005 Mental Capacity Act, and provides much helpful advice here. The legal uncertainties about whether an IMCA should be involved when making a DNAR decision on someone without relatives is problematic: The suggestion to involve an IMCA may often prove impractical. The advice here seems to run contrary to the pragmatic approach found in the rest of this policy guideline.
7. Bizarre difficulties have arisen when patients are moving from the host hospital to another institution for palliative and terminal care, and have then suffered an arrest either in the ambulance, or shortly after arriving at the new centre. The advice here is pragmatic, and contains examples of where ambulance trusts have adopted sensible policies. This guideline will encourage all localities to address this issue and find sensible solutions.
8. The section on reviewing the DNAR has changed little from the 2001 guidance. It would be helpful if this section was amplified. It is unclear what is required from a routine review of a DNAR decision, as in the large majority of cases the clinical situation will be unchanged. Clearly it would be undesirable to have repeated discussions with the patient. Clearly if the patient’s condition improves, or there is an improvement in the prognosis, then the DNAR decision requires review.
9. Finally, the draft document invites comment on whether there is fourth scenario, apart from the scenarios of clinically unlikely to survive CPR, arrest unlikely, and risk of arrest and possibility of survival hence the need for discussion. The fourth scenario is where death is expected quite soon, yet it is considered that survival following CPR may be possible, if only for a few days. In my opinion, it is best to try and assign each patient into one of the main three scenarios. Where survival from CPR might be achieved prolonging life if only for a few days, then discussion with the patient is necessary to ensure that the medical staff understand fully the patient’s wishes for how they are to be treated in their last days and weeks of life.

Professor Peter Crome MD PhD FRCP FFPM
President
For and on behalf of British Geriatrics Society
13 August 2007