Fri 24 Feb, 2006 04:14 pm
Doctor questions the logic of reviving care home residents
Friday, 24 February 2006
THE policy of automatically trying to resuscitate an elderly care home resident who has a heart attack should be reconsidered, as the chances of success are so low, according to a paper in the British Medical Journal.
Dr Simon Conroy, a clinical lecturer in geriatrics at Queen's Medical Centre in Nottingham, and colleagues said that the chances of reviving someone in this situation varied from between zero and 6 per cent, compared with 14 per cent in an acute hospital. Even then, the survivors often suffer a further deterioration in their health.
The authors of the paper said a cost-benefit analysis might show that resources would be better spent elsewhere. "If one person in a care home or hospital is to be provided with cardiopulmonary resuscitation, all staff require training and the appropriate resources need to be funded," the paper said.
"Given the likely low chance of success, it may be that the institution should not offer resuscitation at all. Resources saved by not spending time in training and the subsequent discussions could be better used in improving the quality of care.
"Potential clients or their representatives could be given a statement explaining the non-resuscitation policy of the institution. They would then be able to choose whether to accept or decline."
The paper said making the best use of available resources was an important part of ensuring justice in healthcare. "Dramatic, life-saving interventions have often been thought of as having first call on resources, but there is no reason why their costs and benefits should not be appraised like those of other treatments," the authors said.
"If the chances of success were low (perhaps less than 2 per cent or 5 per cent), a 'do not resuscitate' order could be issued without further discussion, unless the patient or resident requested it.
"In this case, the discussion would largely be an explanation of 'why not', rather than a negotiation about 'whether'."
The paper said a typical nursing home might look after about 70 people and expect 46 deaths a year.
"Even assuming that cardiopulmonary resuscitation is provided to six residents a year, with a survival to discharge rate of 2 per cent, only one person might survive every eight years," it said.
"The survivor would have a 30 per cent chance of useful recovery, probably from an already poor state of health. Staff would spend large amounts of time explaining resuscitation to each new resident and be diverted from generally under-resourced core care activities."
Original article (subscription or to be paid for): Cardiopulmonary resuscitation in continuing care settings: time for a rethink?
Conroy et al. BMJ.2006; 332: 479-482.
I know the nursing home where my mother spent her last 4 years required any DNR statement to be signed by everyone in the immediate family, including her grandchildren. I think this is going a bit far - she had 11, and at least one of them was mostly at sea. If I remember correctly, the form was not required unless the family requested DNR. Without the form, resucitation would automatically be attempted.
If DNR measures were to be automatically put in place when someone enters a nursing home, a relative (or the person her/himself, if capable) must obviously be given the choice to opt out.
We consulted with my mother, who was at that time still sufficiently with it mentally, to make the decision to put a DNR request in place.
I personally think this is a great idea.
Having worked in many nursing homes , I know that ... in general.. 70% of the population already has a DNR in order.
Alot of the times, with just a handful of people with OUT a DNR, it would cause confusion, and on more then one occasion, CPR was begun on someone who had already chosen not to have it .
Speaking from my experience only,
Nursing homes are not the place people are going to ensure a long life. Most of the times, from what I have seen, this was a place to go to die with a doctor on call.
Alot of people think that nursing homes are like hospitals and that anything that can be done in a hospital can be done in these places. And the assumption that everyone would want to be saved at any time is passed around freely. No matter what the person/patient is suffering from.
Most people who judge against DNR orders, have never set foot in a nursing home to see what the ' quality of life' really means.
9 times out of 10 when someone reaches a nursing home, they require 24/7 care. All the way down to having a diaper changed because they are no longer mentally capable of even asking to go, let alone knowing when they have to go.
This isn't a way anyone would ever choose to live.
At this time in peoples lives, the body is so weak from age , disease.. or what have you, that most people can not even survive the possible side effects from something simple like CPR.
CPR on an elderly person is almost always the cause of broken ribs, and in rare but serious cases, punctured lungs.
The simple pressure that is required for CPR to be effective, is too much for aging , already brittle bones.
I personally have NOT done CPR on an elderly person where I DIDNT cause a broken or cracked rib bone.
Not to mention a possible Trach in certain situations either. Those can collapse the throat muscles causing the person to have little or no control of the basic movement of swallowing, or even breathing.
If a nursing home chose to be an entirely DNR based facility... I think it would be a wonderful decision.
In Canada, at least in the hospitals I have been in, at least for the relatives I have watched die, some of the nurses have confided in me that the staff will provide opiate based pain reducing medications, to the point of making the last bit more tolerable, with the added benefit of speeding the death process.
It's not official euthanasia by any means, but all things are not done at all times to all patients in an effort to extend life.
The only thing I know about nursing homes in England, is that nursing care is provided free in, but supposed personal or social care is means-tested and charged to those deemed able to pay for it. (Which is in one case, I know of, quite a lot of money per month for the son.)
In Germany, the situation is very similar - actually identical.
Generally, I thing, that the elderly are not an inconvenience but simply older people, some of whom need our help and should not be viewed as draining money away from other places.
In whatever mental state a person is in, they should never have their choices taken away from them, and if they do not wish to be ressucitated - that their choices.
But they shouldn't loose their rights only because they are in a care home.
My father had been the leading physician of a 'care hospital' for a couple of years, with Mrs. Walter (got a training in elderly care) I take care of my mother after her stroke and of my aunt, who's depressive (additional to home care by nurses, since a senor residence/care home is no choice due to various reasons).