Biegler, P, Stewart, C, et al. (2000). "Determining the validity of advance directives." Medical Journal of Australia 172: 545-8.

We examine the ethical principles underpinning advance directives (ADs) and the legal duties of doctors in determining their validity.
A physician attending an incompetent patient with an acute life-threatening illness, and an AD refusing treatment, should ensure that the AD is legally valid before making the treatment decision.
Treatment against a patient's wishes, as expressed in a valid AD, compromises patient autonomy and may constitute battery. Conversely, withholding treatment in accordance with an AD that is not legally valid risks substantial harm to the patient and may constitute breach of the duty of care and negligence.
Legally valid directives should be respected. If an AD is not legally valid, the patient should be treated in his or her best interests. If uncertain, the physician should treat according to the patient's best interests while seeking legal advice.

Biegler, P (2001). "Advance directive knowledge and research appears lacking in Australia: Comment." Emergency Medicine 13(1): 127-8.

Letter to the editor in regards to Taylor D & Tan SL. (2000). "Advance directive knowledge and research appears lacking in Australia" Emergency Medicine, 12: 255-6.

Bradley, E, Peiris, V, et al. (1998). "Discussions about end-of-life care in nursing homes." Journal of the American Geriatrics Society 46(10): 1235-41.

Objective: To measure the frequency with which nursing home residents and their surrogates discuss with clinicians the resident's wishes concerning future treatment and to assess the influence of the Patient Self Determination Act (PSDA) on the frequency and nature of such discussions.
Design: Retrospective cohort study of residents admitted to nursing homes before and after the PSDA.
Setting: Six large (at least 120 licensed chronic care beds), randomly selected nursing homes in Connecticut.
Participants: Six hundred randomly selected nursing home residents admitted during 1990 and 1994 to one of the six study nursing homes.
Measurements: Documented discussions concerning future treatment wishes were abstracted from residents' nursing home medical records. Participants in the discussion, as well as the timing (i.e., date) and content of the documented discussions were recorded. Sociodemographic and health status factors were also obtained from the medical record.
Results: A large majority of residents (71.5%) had no discussion of future treatment wishes documented in their medical record. However, the percentage of residents with documented discussions had increased since the implementation of the PSDA (36.7% post-PSDA vs 20.3% pre-PSDA). Of those in the post-PSDA cohort who had had discussions, 90% had only one discussion within the first year of admission, and more than half (58.1%) of those who had discussions discussed only life-support systems (cardiopulmonary resuscitation, artificial nutrition and hydration, and ventilation) rather than broader preferences for future treatment, including proxy decision-making.
Conclusions: Despite the increased prevalence of discussions about future treatment wishes since the enactment of the PSDA, no discussions were documented for most residents. For those with documented discussions, such conversations occurred rarely and were narrow in scope, suggesting that residents' and families' roles in medical decision-making in nursing homes may be limited.

Brook, R (2000). "Dying on our own terms." Time Sept 18: 60-73.

Too many Americans spend their final days in a hospital or nursing home, alone and in pain. It doesn't have to be that way.

Coppola, K, Ditto, P, et al. (2001). "Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives." Archives of Internal Medicine 161(3): 431-40.

Background: Past research has documented that primary care physicians and family members are often inaccurate when making substituted judgments for patients without advance directives (ADs). This study compared the accuracy of substituted judgments made by primary care physicians, hospital-based physicians, and family surrogates on behalf of elderly outpatients and examined the effectiveness of ADs in improving the accuracy of these judgments.
Participants and Methods: Participants were 24 primary care physicians of 82 elderly outpatients, 17 emergency and critical care physicians who had no prior experience with the patients, and a baseline comparison group of family surrogates. The primary outcome was accuracy of physicians' predictions of patients' preferences for 4 life-sustaining treatments in 9 hypothetical illness scenarios. Physicians made substituted judgments after being provided with no patient AD, patient's value-based AD, or patient's scenario-based AD.
Results: Family surrogates' judgments were more accurate than physicians'. Hospital-based physicians making predictions without ADs had the lowest accuracy. Primary care physicians' accuracy was not improved by either AD. Accuracy and confidence in predictions of hospital-based physicians was significantly improved for some scenarios using a scenario-based AD.
Conclusions: Although ADs do not improve the accuracy of substituted judgments for primary care physicians or family surrogates, they increase the accuracy of hospital-based physicians. Primary care physicians are withdrawing from hospital-based care in growing numbers, and emergency medicine and critical care specialists most often are involved in decisions about whether to begin life-sustaining treatments. If ADs can help these physicians better understand patients' preferences, patient autonomy more likely will be preserved when patients become incapacitated.

Darr, K (1999). "Implementing advance directives: A continuing problem for provider organizations." Hospital Topics 77(3): 29-32.

Deals with several types of advance directives and the rights of patients in the United States to formulate their own advance directives. Impact of the Patient Self Determination Act of 1989 on the number of patients with advanced directives; Living wills; Natural death act statutes; Do-not-resuscitate orders; Substituted judgment; Problems with advance directives; Improving availability and use of advance directives.

Ditto, P, Danks, J, et al. (2001). "Advance directives as acts of communication. A randomized controlled trial." Archives of Internal Medicine 161(3): 421-30.

Background: Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions.
Participants and Methods: A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured.
Results: None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation.
Conclusions: Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.

Gerson, L, Blanda, M, et al. (2001). "Do elder emergency department patients and their informants agree about the elder's functioning?" Academic Emergency Medicine 8(7): 721-4.

Objective: To compare elder patients' and their informants' ratings of the elder's physical and mental function measured by a standard instrument, the Medical Outcomes Study Short Form 12 (SF-12).
Methods: This was a randomized, cross-sectional study conducted at a university-affiliated community teaching hospital emergency department (census 65,000/year). Patients >69 years old, arriving on weekdays between 10 AM and 7 PM, able to engage in English conversation, and consenting to participate were eligible. Patients too ill to participate were excluded. Informants were people who accompanied and knew the patient. Elder patients were randomized 1:1 to receive an interview or questionnaire version of the SF-12. The questionnaire was read to people unable to read. Two trained medical students administered the instrument. The SF-12 algorithm was used to calculate physical (PCS) and mental (MCS) component scores. Oral and written versions were compared using analysis of variance. The PCS and MCS scores between patient-informant pairs were compared with a matched t-test. Alpha was 0.05.
Results: One hundred six patients and 55 informants were enrolled. The patients' average (±SD) age was 77 ± 5 years; 59 (56%; 95% CI = 46% to 65%) were women. There was no significant difference for mode of administration in PCS (p = 0.53) or MCS (p = 0.14) scores. Patients rated themselves higher on physical function than did their proxies. There was a 4.1 (95% CI = 99 to 7.2) point difference between patients' and their proxies' physical component scores (p = 0.01). Scores on the mental component were quite similar. The mean difference between patients and proxies was 0.49 (95% CI = 3.17 to 4.16). The half point higher rating by patients was not statistically significant (p = 0.79).
Conclusions: Elders' self-ratings of physical function were higher than those of proxies who knew them. There was no difference in mental function ratings between patients and their proxies. Switching from informants' to patients' reports in evaluating elders' physical function in longitudinal studies may introduce error.

Ghusn, H, Teasdale, T, et al. (1997). "Continuity of do-not resuscitate orders between hospital and nursing home settings." Journal of the American Geriatrics Society 45(4): 465-9.

Objective: To determine the relationship between interinstitutional communication and continuity of advance directives from hospital to nursing home (NH) settings.
Design: Retrospective chart review of discharges to hospital affiliated or community NHs.
Setting: Teaching Veterans Affairs Hospital and affiliated and community nursing homes.
Measurements: Demographic characteristics, medical diagnoses, presence of advance directives, and documentation that relates to the topic.
Results: A total of 83 patients were discharged to either setting. Before discharge to a NH, the prevalence of chronic obstructive pulmonary disease and cancer was higher among those who had a DNR order. Overall, subsequent discussions about advance directives were equally common in NHs. Having a hospital discussion about advance directives or having a hospital DNR order were associated with a higher rate of advance directive discussions in NHs. Hospital DNR orders were continued for 93% and 41% of patients admitted to the hospital-affiliated NH compared with community NHs, respectively (P < .001). Specific communication of hospital DNR status to the receiving NH was associated with better continuity of DNR orders (49% vs 9%, P = .001). Factors that predicted continuity of DNR orders in logistic regression analysis correctly included hospital DNR status, communication of advance directives to the receiving NH, and NH advance directive discussions.
Conclusions: There is higher continuation rate of DNR orders between the hospital under study and its affiliated NH than to community NHs despite a similar frequency of confirmation discussions. Completing advance directives before patients are discharged to NHs, communication of advance directives to the receiving NH, and follow-up discussions at the NH may improve the continuity of advance directives between hospitals and nursing homes.

Gillick, M, Berkman, S, et al. (1999). "A patient-centered approach to advance medical planning in the nursing home." Journal of the American Geriatrics Society 47(2): 227-30.

Objective: The objective of this study is to determine whether nursing home residents or their surrogates are willing and able to prioritize their goals for care and to demonstrate how these rankings can form the basis of a specific pattern of medical care.
Design: A prospective, descriptive study.
Setting: A 40-bed nursing unit for residents with mild to moderate impairments in a 725-bed teaching nursing home.
Results: Overall, 78% of patients or their families were willing to prioritize their goals, allowing the investigators to infer a pattern of care. The goals were interpreted as implying an intensive pattern in 21%, a comprehensive pattern in 16%, a basic pattern in 18%, palliation in 18%, and comfort only in 6% of residents. Goals chosen by residents who were able to select for themselves translated into more aggressive care than did the goals selected by surrogates.
Conclusion: Goal-centered advance medical planning can be initiated in nursing homes by asking residents or their surrogates to prioritize their goals of care. These prioritizations can form the foundation for specific patterns of care.

Goss, R (2001). "Without discussion, these orders are unethical at any age." British Medical Journal 322(7278): 102.

FULL LETTER
The subheading to Ebrahim's editorial on do not resuscitate decisions is: "Resuscitation should not be withheld from elderly people."1 Surely doctors should say instead that resuscitation must not be withheld. . . ." Ebrahim spells out the reality hiding behind the rhetoric of the BMA, Resuscitation Council (UK), and Royal College of Nursing. It would help if hospitals were required when booking in patients to offer them the opportunity to complete a form indicating, among other things, their attitude to resuscitation, whether they have a living will, and if they consider starving to death (under certain circumstances) to be acceptable.
The current practice of treating elderly patients and their relatives with total disrespect negates every principle of what constitutes a civilised health service. It is hardly surprising that Patient Concern is being inundated with requests for its "How to Survive" leaflets by people terrified at the prospect of having to go into hospital.2-4 (Each leaflet is available from the organisation for two first class stamps.) I would add only that the usual hopeless solution includes guidelines.
Do not resuscitate orders at any age, without discussion, are unethical. Eradicating this practice in the NHS requires legislation, full stop.
References
1. Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death? BMJ 2000; 320: 1155-1156
2. Robins J. How to survive surgery. London: Patient Concern, 2000.
3. Robins J. How to survive doctors. London: Patient Concern, 2000.
4. Robins J. How to make a living will. London: Patient Concern, 2000.

Johnston, S, Pfeifer, M, et al. (1995). "The discussion about advance directives." Archives of Internal Medicine 155(10): 1025-30.

Background: Widely publicized court cases have focused national attention on the importance of advance directives. In spite of initiatives such as the Patient Self-Determination Act of 1991, fewer than 10% of Americans have prepared advance directives. One way to increase the preparation of advance directives may be to increase the frequency and quality of discussions about them between individual patients and their physicians. We performed a multicenter observational study to assess the opinions of primary care patients and physicians regarding these discussions.
Methods: This was a cross-sectional descriptive survey of randomly selected primary care patients and physicians in eight primary care internal medicine clinics in the eastern and midwestern United States. Quantitative questionnaires were used to elicit subjects' demographic characteristics, and their opinions regarding the timing, content, and location of discussions about advance directives.
Results: The 883 subjects included 329 adult outpatients, 282 resident physicians, and 272 practicing physicians. Physician and patient response rates were 75% and 76%, respectively. Patients felt that the discussion should occur earlier than did the physicians: at an earlier age, earlier in the natural history of disease, and earlier in the patient-physician relationship. Most subjects agreed it was the physician's responsibility to initiate the discussion.
Conclusion: We defined a discrepancy between the preferences of primary care patients and physicians regarding the timing of the discussion about advance directives. We propose physician education regarding patient preferences as the most effective way to accomplish the goal of improving the frequency and quality of discussions about advance directives.

Lindley, R, B, B, et al. (2001). "More consumer education and involvement are needed." British Medical Journal 322(7278): 102.

FULL LETTER
In response to Age Concern's campaign on cardiopulmonary resuscitation1 we designed and completed an audit of the views of patients in our hospital. We conducted our questionnaire survey, administered by medical students, between 25 April and 1 May 2000 at a hospital for older people (aged >65) and stroke rehabilitation. We interviewed only patients who were documented as being for resuscitation in the event of a cardiorespiratory arrest.
Twenty eight patients were interviewed in the time available. Nineteen thought that cardiopulmonary resuscitation had a 50% or greater success rate. Eight considered that a "not for cardiopulmonary resuscitation" order would detrimentally affect their general care (six thought it could improve their care). Few (three people) thought that age should influence cardiopulmonary resuscitation status. Most (24) correctly recognised that doctors currently make the decisions on cardiopulmonary resuscitation, but in their opinion they and their relatives should be equally involved in the decision.
Our sample of patients had an overoptimistic view of the potential success of cardiopulmonary resuscitation. We also found that they may worry about the implications of their cardiopulmonary resuscitation status, as some were concerned that their further care might be adversely affected. The risks of discussing cardiopulmonary resuscitation status with patients need to be considered by all healthcare professionals. Overall, our survey supports the view that more consumer education and involvement are needed.2
1. Age Concern England. Turning your back on us older people and the NHS. London: Age Concern, 2000.
2. Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death. BMJ 2000; 320: 1155-1156

MacQueen, R (2001). "All -isms are intolerable." British Medical Journal 322(7278): 102.

FULL LETTER
Ebrahim's editorial on entrenched ageism shows the ugly side of medical practice.1 Perhaps we cannot help it; we are humans and products of our time and culture. We are tribal creatures, and unless the forces maintaining tribalism are addressed it will remain.
Working among people who have problems with alcohol, other drugs, and mental health, my colleagues and I see classism, ageism, and racism daily. My belief is that our culture has defined which health problems are "more unpleasant" and which are "less unpleasant"; not surprisingly, the nicer ones are those that the vocal, well connected, well off middle class have. They can usually be externalised and treated with high tech, high cost interventions. Heart disease and certain cancers are in this group. But younger, less vocal people with drug problems or mental health problems are not in this group; their problems are "internal" problems, perhaps due to moral weakness (yes, even in this enlightened age) and not at all pleasant. Ignore them if possible, even if these problems are the most important of all health issues for the global burden of disability.
What of Virchow's admonition that we are the natural attorneys of the poor and should solve social problems? It's not just ageism we should fight, it's all of the -isms, now creeping back into a surgery or hospital somewhere near you.
References
1. Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death? BMJ 2000; 320: 1155-1156

Marco, C and Larkin, G (2001). "A time to die. Patient-centered priorities in cardiac resuscitation." Academic Emergency Medicine 8(5): 475.

Objectives: This study was undertaken to elucidate public preferences regarding the relative importance of a variety of factors at the end of life.
Methods: This multisite cross-sectional survey was administered to 1,831 volunteer lay participants in multiple community-based settings during May-August 2000.
Results: Among 1,831 participants representing 38 states, the mean age was 39 (range 14-98), and 55% were females. Participants rated each of the following factors for importance in the event of their own cardiac arrest: (at http://intl.aemj.org/cgi/content/abstract/8/5/475-a)
Participants also indicated which factors should be considered by physicians making decisions regarding the initiation and termination of resuscitative efforts: (at http://intl.aemj.org/cgi/content/abstract/8/5/475-a)
Conclusions: Most participants indicated that patient and family wishes should be considered of utmost importance, above that of physician opinion and other factors in decision making regarding resuscitative efforts. Additionally, most participants indicated that advanced technology and physician communication are of foremost importance in the resuscitation setting. Most participants did not consider family presence in the resuscitation room of significant importance.

Molloy, D, Guyatt, G, et al. (2000). "Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial." Journal of the American Medical Association 283(11): 1437-44.

Context: Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation.
Objectives: To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs.
Design: Randomized controlled trial conducted June 1, 1994, to August 31, 1998.
Setting and Participants: A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each.
Intervention: The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives.
Main Outcome Measures: Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes.
Results: Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20).
Conclusion: Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.

Molloy, D, Russo, R, et al. (2000). "Implementation of advance directives among community-dwelling veterans." Gerontologist 40(2): 213-7.

To evaluate the feasibility and effectiveness of implementing a "Let Me Decide" advance directive education program among veterans living in the community, the authors studied 150 veterans in south central Ontario. Thirty-four veterans had preexisting Powers of Attorney and were removed from the analysis, leaving a total sample of 116. Two methods of systematically implementing a directive program were evaluated after the intervention period and 6 months later. Eighty-two (71%) of the 116 veterans expressed interest in receiving detailed information about the program, and 67 (82%) of the 82 interested veterans were educated. Forty-two (63%) of the 67 educated veterans completed directives. Of the 116 interested veterans, 42 (36%) completed directives. Veterans who were educated about directives were surveyed at follow-up, and 37 of 38 (97%) respondents reported that the education process was beneficial and should be offered to other veterans. This response pattern was consistent among those who completed and those who did not complete directives.

O'Leary, M (2001). "Doctors must always act in their patients' best interests." British Medical Journal 322(7278): 102.

FULL LETTER
I am increasingly disappointed at efforts to remove the duty of care for patients from doctors into the hands of relatives or, even worse, the courts. I thought that I spent five years at medical school and 12 years in postgraduate training in order that I might have the knowledge and experience to care for patients in a professional manner. This means treating the patients when it is appropriate to do so and not treating them when it is inappropriate to do so.
Now I am being told that even when it may be clear to me that a patient will not benefit from treatment (in this case cardiopulmonary resuscitation1) I must first ensure that this has been discussed with the family. How can family members have the required understanding of prognosis and treatment implications and the objectivity to make such a decision? What if the family disagrees? Am I then compelled to offer the futile treatment? Unfortunately, many doctors already seem to take this route; evidence the hopeless case in the intensive care unit, there because the family wanted everything done and now slowly dying without dignity.
Society is forgetting that death is an integral part of life and eventually comes to us all. It is becoming common practice for relatives, on finding someone dead at home, to call an ambulance. In the past it would have been the priest. Doctors' primary role is not to prevent death but to treat illness and alleviate suffering. Identifying patients for do not resuscitate orders is vital in modern high technology medical practice to prevent loss of dignity in otherwise inevitable deaths. Most patients with do not resuscitate orders will, I am afraid, be elderly with cancer, dementia, or other severe underlying illness limiting their life expectancy. This is not ageism but caring medical practice.
References
1. Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death? BMJ 2000; 320: 1155-1156

Pauls, M, Singer, P, et al. (2001). "Communicating advance directives from long-term care facilities to emergency departments." Journal of Emergency Medicine 21(1): 83-9.

Many residents of long term care (LTC) facilities are transferred to Emergency Departments without advance directives (AD). The goal of this study was to describe an ideal model for the transfer of AD from LTC facilities to Emergency Departments. Health care providers were asked to describe their ideal model for the completion and transfer of the ADs to LTC residents. A grounded theory methodology was used to identify significant themes. The model we present as a result of this analysis acknowledges the importance of simplifying and standardising ADs, but focuses more attention on the process of completing and transferring the AD. A key feature of this model is an emphasis on the education of LTC residents and their relatives about ADs and advance-care planning. This education should involve a variety of resources used in creative ways; it should begin as soon as LTC placement is being considered, and the emphasis should be on providing information and discussing options rather than pressuring residents to make a decision.

Quill, T (2000). "Initiating end-of-life discussions with seriously ill patients. Addressing the "elephant in the room"." Journal of the American Medical Association 284(19): 2502-7.

Discussions about end-of-life issues are difficult for clinicians to initiate. Patients, their families, and clinicians frequently collude to avoid mentioning death or dying, even when the patient's suffering is severe and prognosis is poor. In addition to determining from observational research when and where communication problems exist, much can be learned from in-depth discussions with patients, family members, and physicians who are facing these issues together. Using segments of interviews with a patient with advanced pulmonary fibrosis, his son, and his primary care physician, this article illustrates and explores some of these communication issues, including the who, what, when, why, and how of end-of-life discussions. Studies from the medical literature, the patient's and physician's particular experience together, and the author's clinical experience provide practical insights into how to address these issues. Initiating end-of-life discussions earlier and more systematically could allow patients to make more informed choices, achieve better palliation of symptoms, and have more opportunity to work on issues of life closure.

Sanders, A (1999). "Advance directives." Emergency Medicine Clinics of North America 17(2): 519-26.

Different types of advance directives invite varying interpretation from emergency care professionals. As informed consent of a patient is not always possible to procure in emergency situations, advance directives can provide useful guidelines for clinicians' decision-making processes regarding individual patient care. Specifically communicated instructions establish a course of aggressive or nonaggressive treatment, while general wishes leave the emergency department physician to assume an innate understanding of individual patients while undertaking an active role in decision-making for that patient's care. This article explores the relationship between advance care directives and the emergency department.

Smith, G (2001). "Sound clinical reasons for withholding cardiopulmonary resuscitation must not be confused with ageism." British Medical Journal 322(7278): 102.

FULL LETTER
Contrary to Ebrahim's comments in his editorial,1 the 1999 statement on cardiopulmonary resuscitation by the BMA, Resuscitation Council, and Royal College of Nursing does not demand discussion with the patient or close relatives before a do not resuscitate order can be considered.2 Indeed, it seems totally inappropriate, illogical, unkind, and potentially unethical that healthcare professionals should be compelled to discuss any form of ineffective treatment with a patient. Furthermore, as healthcare professionals are not obliged to provide any treatment that cannot produce the desired benefit3 it seems particularly cruel to offer cardiopulmonary resuscitation in circumstances where evidence indicates that it will be ineffective and then to refuse to administer it anyway.
Age Concern's finding that elderly patients are given do not resuscitate orders does not necessarily suggest ageism. There is much evidence that elderly patients do receive cardiopulmonary resuscitation. Altogether 55% of patients in the British hospital resuscitation (BRESUS) study were aged over 65, with a quarter being over 75.4 I would suppose that when do not resuscitate policies were applied there were good clinical reasons for the intended withholding of cardiopulmonary resuscitation.
References
1. Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death? BMJ 2000; 320: 1155-1156
2. British Medical Association, Resuscitation Council (UK), Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation; a joint statement. London: BMA, RC(UK), RCN, 1999.
3. British Medical Association. Withholding and withdrawing life-prolonging medical treatment. Guidance for decision making. London: BMA, 1999.
4. Tunstall-Pedoe H, Bailey L, Chamberlain DA, Marsden AK, Ward ME, Zideman DA. Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS study): methods and overall results. BMJ 1992; 304: 1437-1451.

Stewart, K and Bowker, L (1998). "Advance directives and living wills." Postgraduate Medical Journal 74(869): 151-6.

Under certain circumstances, living wills or advance directives may carry legal force in the UK. This paper traces the development of advance directives, clarifies their current legal position and discusses potential problems with their use. Case histories are used to illustrate some of the common dilemmas which doctors may face.

Stewart, K and Spice, C (2001). "Not discussing decisions is often because of practicalities, not ageism." British Medical Journal 322(7278): 102.

FULL LETTER
We strongly support Ebrahim's attack on ageism in the health service but think that he was unwise to illustrate his point by referring to the use of do not resuscitate orders.1 The situation is not nearly as clear cut as he would have readers believe.
We make resuscitation decisions regularly; we sometimes discuss these with relatives, less often with patients. The reasons for not discussing decisions have little to do with ageism and much to do with practicalities. Most survivors of resuscitation have their arrest on their first or second day in hospital, so decisions have to be made at a time when many elderly patients are legally incompetent to decide, either because of confusion or because of the severity of their illness. In a small British study most patients could not recall important details about resuscitation a week after the discussion.2 We often try to contact relatives on these occasions, but this in itself causes problems. Under current law if patients are incompetent then responsibility for medical decisions passes to their doctors, not their family; many people are unaware of this.
What if decisions are made because resuscitation is so unlikely to succeed that it can be regarded as futile? Is there an obligation to tell patients or relatives about this (and other potentially lifesaving treatments that are to be withheld on this basis)? The most recent guidelines avoid giving a clear answer.3
Ebrahim states that most patients and relatives want to discuss death and do not resuscitate decisions, but this is not our experience and is not supported by the literature. We are regularly asked to avoid discussing diagnoses of cancer and other serious illness for fear of causing distress. British studies of patients' views about resuscitation are consistent with this; some patients want to be involved in decisions or have their relatives consulted and others do not, while some want doctors to decide.4 Heller et al became the subject of press criticism for attempting to discuss resuscitation with all elderly patients and were accused of rationing care and advocating euthanasia.5
Doctors who face these problems in their work would appreciate an editorial telling them how its author manages to discuss all the do not resuscitate decisions that he or she has to make and how the practical difficulties that we have described can be overcome.
References
1. Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death? BMJ 2000; 320: 1155-1156
2. Sayers GM, Schofield I, Aziz M. An analysis of CPR decision-making by elderly patients. J Med Ethics 1997; 23: 207-212
3. British Medical Association, Resuscitation Council (UK), Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation; a joint statement. London: BMA, RC(UK), RCN, 1999.
4. Stewart K. Discussing cardiopulmonary resuscitation with patients and relatives In: Hind CR, ed. Communication skills in medicine. London: BMJ Publishing Group, 1997.
5. Heller A, Potter J, Sturgess I, McCormack P. Resuscitation and patients' views: Questioning may be misunderstood by some patients. BMJ 1994; 309: 408

Taylor, J, Heyland, D, et al. (1999). "How advance directives affect hospital resource use - Systematic review of the literature." Canadian Family Physician 45: 2408-13.

Objective: To assess whether advance directives influence resource use by hospitalized patients.
Data Sources: A systematic search of computerized medical databases, reference lists from relevant articles, and personal files was conducted to identify studies examining the association between advance directives and resource use.
Study Selection: Primary studies assessing the effect of advance directives on hospital resource use were selected if they had a clear quantitative measure of hospital resource use, hospitalized patients as a study population, a control group for comparison, and a description of the advance directive being studied. Data on the following topics were abstracted from studies meeting inclusion criteria: study methods and design, resource use, source of financial data, description of advance directive, population size and composition, length of assessment.
Synthesis: Six studies met inclusion criteria. Three retrospective studies showed significant reductions in resource use associated with documentation of advance directives while three prospective studies (two randomized, one not randomized) showed no association between advance directives and reduced resource use. Studies were limited to narrowly defined patient populations in US tertiary care hospitals.
Conclusions: Little evidence supports the hypothesis that advance directives reduce resource use by hospitalized patients. Some retrospective studies have shown savings, but their conclusions are weakened by shortcomings in study design. Prospective trials, which have better experimental methods, have demonstrated no evidence of cost savings with the use of advance directives.

Tunstall-Pedoe, H (2001). "Resuscitation should not be part of every death." British Medical Journal 322(7278): 102.

FULL LETTER
Pioneers of cardiopulmonary resuscitation in the 1960s were medical heroes. They would be surprised to find their treatment for hearts that were too young to die becoming an obligatory death rite for all, and themselves anathematised for mentioning the new taboo of age.1
Feedback that I, as chairman of Tayside cardiopulmonary resuscitation committee, receive from junior hospital staff is that inappropriately initiated cardiopulmonary resuscitation is common, emotionally fraught, and demotivating; inappropriate failure to initiate cardiopulmonary resuscitation is virtually unknown. Seemingly false positive results therefore heavily outnumber false negative results, but parallel audits of deaths and cardiopulmonary resuscitation are now being conducted to relate the two.
Ebrahim wishes to increase cardiopulmonary resuscitation in elderly patients, recommending legislation and quoting American attitudes and evidence in support.1 Attitudes and practices cannot be imported uncritically from the United States, a lawyer-ridden society. If they were, ward rounds would end up being led by civil rights lawyers, medical ethicists, and their interpreters. Doctors would then be informed what equity and empowerment obliged them to do, rather than use their clinical judgment, which balances potential benefit against potential harm.
Cardiopulmonary resuscitation appears miraculous; hence the view that there should be miracles for all on the NHS and that cardiopulmonary resuscitation is somehow different from other treatments in not being a matter for medical discretion. Behind this expectation are two sources of confusion.
According to the Oxford English Dictionary, resuscitation means restoring life from apparent death, with overtones of the resurrection of Christ.2 Medical practice has introduced semantic confusion by corrupting the term to mean the often vain attempt to restore life. The second source of confusion is that cardiopulmonary resuscitation was developed to treat the effects of reversible precipitants of sudden death. Even in chronic progressive disease the transition to death is momentary and therefore sudden. This makes the distinction between sudden and non-sudden death arbitrary and difficult to define medically, or for would-be legislators. The potential for pressure groups to make a point by publishing details of unfortunate cases and selected case series to the detriment of public confidence is virtually unlimited.
Tayside resuscitation policy is to avoid the phrase "not for resuscitation" because of the semantic confusion and to write in the notes "cardiopulmonary resuscitation currently inappropriate: decided by [name], discussed with [names]. To be reviewed by [identify who] in/on [time interval or date]." The policy states that written instructions are not always possible and that judgment on treatment is the ultimate prerogative of the medical team, taking account of all the circumstances, which often change.
References
1. Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death? BMJ 2000; 320: 1155-1156
2. Oxford English dictionary. 2nd ed. Oxford: Oxford University Press, 1999.