Elderly Patients Being 'Written Off' in UK, US

By Patrick Goodenough | July 7, 2008 | 8:08 PM EDT

London (CNSNews.com) - Many doctors in Britain are deciding they will not attempt to revive seriously ill older patients, and are not discussing the decision with the patients or family members involved.

The tendency appears to be active in the United States as well.

A British charity for the elderly says it has been inundated with calls from people - mostly relatives of patients who have died - who say National Health Service (NHS) staff are playing God when it comes to life-and-death decisions.

Triggered by publicity about one case, they have presented the charity, Age Concern, with information on more than 100 cases where patients' medical charts were marked with phrases like "not for resuscitation," a spokesperson told CNSNews.com.

In a typical case, 67-year-old cancer patient Jill Baker discovered after she left hospital that, had she fallen unconscious while there, the staff would have made no attempt to revive her. The comment "inappropriate for resuscitation" had been written on her medical notes, without the agreement or knowledge or her or her husband.

Nine months later, she is living a full life.

In another instance, a patient who died in the hospital was found by her family to have
NFR (not for resuscitation) written across her toes.

Professor Shah Ebrahim, of the University of Bristol's Department of Social Medicine, said in an article in the British Medical Journal published Friday that legislation was needed to ban doctors from deciding not to resuscitate seriously ill patients without consultation.

He said doctors may be against attempts to revive some patients as a result of prejudice.

NFR orders were more often used for elderly patients, while studies in the United States indicated that the orders there were more commonly used for blacks, non-English speakers, alcohol abusers and HIV-positive patients.

This suggested that "doctors have stereotypes of who is not worth saving."

Ebrahim said that merely by deciding in advance not to revive a patient if he or she falls unconscious, medical staff may in effect be condemning the patient to a lower level of care.

"After adjustment for disease severity [and other risk factors] ... patients given these orders are 30 times more likely to die, suggesting that do not resuscitate orders may reduce quality of care."

More than two-thirds of patients with NFR orders had not been involved in making these decisions, he said, citing studies in Europe.

Ebrahim told CNSNews.com that no studies had yet been carried out in Britain on what criteria other than age were being used by doctors making these decisions.

"I think we need to do the studies before we conclude that British doctors do not behave in similar ways [to those in the U.S. research]."

Asked why he thought the problem was happening, Ebrahim said doctors' failure to discuss the question of whether to try revive a patient probably reflected anxiety about raising the possibility of death - a perceived medical failure.

"I don't think there is a problem of resources or cheapening of human life - just a tendency for doctors to protect their own feelings."

Ebrahim said legislation would probably be needed to counter the problem of "ageism" in the NHS.

"The major concern is that chronological age is used to ration access to health technologies from which elderly people are just as likely to benefit as younger [patients].

"In Britain this includes coronary care units, renal dialysis, coronary revascularisation, and even aspirin for secondary prevention of coronary heart disease."

According to Ebrahim, resuscitation carried out after the heart and lungs stop working is successful one in five times.

Age Concern spokesperson Anna Butterworth told CNSNews.com the charity welcomed Ebrahim's article, which indicated that the problem was being "taken seriously by members of the medical profession."

While Age Concern supported the need for new legislation to protect elderly patients, it wanted the government as a first step to appoint an independent inquiry into the issue.

Without an inquiry, the full extent of the problem, and the reasons for it happening, would remain unknown.

Butterworth said of the 100 cases brought to its attention, many were brought by the younger relatives of the affected person, often after the elderly relation had died.

Not only the very old were affected; in some cases, the patients had been in their 50s, she added.

Most often, neither the patient nor family members had been consulted. Some people claimed that even nursing staff appeared to have taken the decision to mark NFR on the patient chart.

Guidelines in place say doctors should base decisions on clinical need and the express wishes of the patient. If a patient's condition makes it impossible for him or her to make a decision, consent should be obtained from a close relative.

Age Concern said the guidelines are obviously being disregarded.

"The evidence we have received about 'not for resuscitation' points to a disregard of the national guidelines," said Sally Greengross, the charity's director-general.

"Once again we hear from older people who believe they are being written off by the NHS because of their age."

Patrick Goodenough
Patrick Goodenough
Spencer Journalism Fellow