Kill All Old People!

Further to my last post I was sent this link by Lianne (Thanks Lianne)
This article reports on a story in the BMJ, saying that the elderly in NHS nursing homes should not receive CPR.

Writing in the British Medical Journal (BMJ), Simon Conroy, a clinical lecturer in geriatrics, called for a review.

He 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.

(The full article is behind a paywall here)

Please note, I haven't read the full article – I may try to sneak down to Newham Hospital library to have a peek at it.

But I can see a couple of problems with the thinking from just the Daily Mail piece.

First – All NHS nurses are trained in CPR as part of their basic training. It doesn't cost much to keep those skills updated. As I wrote in the previous post, the London Ambulance Service will come out for free and teach you how to perform effective CPR.

70% of cardiac arrests happen outside hospitals, and before the introduction of defibrillators in public places the survival chance was 1%, after the defibs were in place the chance of survival was 3%.

Given the cost of Defibs, was this a worthwhile spending of money? Does the doctor who wrote the article think that putting Defibs in Tesco while removing them from nursing homes is a good idea?

Secondly – Why should we put any money into a treatment that only has a 3-6%(depending on source) success rate? If it is a waste of money to resuscitate the elderly because it has such a low chance of success, then that would apply to any out of hospital arrest.

I'm sorry, but it smacks too much of “let the old ones die” to me – and that is just distasteful. If we start heading down that route, then we may as well stop treating the unemployed or chronically ill because they don't contribute anything to the economy.

My personal view is that CPR is inappropriate in a large number of nursing home cases – but that it should be an individual choice not to be resuscitated and not the default option.

I would have like to have written more, but I'm at work and time/computing resources are limited.

UPDATE: A couple of people have sent me a copy of the article – I'll not mention any names in case it gets them in trouble – but thanks to those who helped. Once I've read it I may post about this subject again.

18 thoughts on “Kill All Old People!”

  1. argh, I said I wasn't supposed to get upset about the Daily Mail…I wonder what “other things” would he like to be doing with the patients rather than encouraging them and their families to consider the issue of whether, in their final days and as part of their care plan, they wish for rescucitation attempts to be made or whether they want to come under a blanket of “no, we're not training the carers to keep you going any more than we really *have* to.”

    Perhaps the patients and their families should just get straight to considering the funeral arrangements and picking a casket – or maybe that time would be better spent doing other things too, and the patients should just be wheeled to the hospital's incinerator for convenience.

  2. you know that the real problem is not the resuscitation of people who are essentialy dead but the care that they receive in these so called nursing homes which leads to these kind of resus decisions. As you've already illustrated in your blog the likelihood of a successful revival is limited to the effort given in the initial collapse. The new ALS guidelines emphasise the importance of bystander CPR and those of us in the resus room have to consider the presence of1: The absence of bystander CPR

    2: Asystole throughout

    The fact is are you and myself are aware the quality of care provided by nursing home staff is sometimes pathetic, however there may be an argument for DNR decisions to be carried forward in those people who are unlikely to benefit from any kind of intervention after discharge from hospital.

  3. I think where this writer might be coming from relates to treatment after these elderly people arrive at the hospital.Even if pre-hospital resuscitation on a person over the age of 80 yrs old does result in a ROSC and they are intubated and ventilated by the Ambulance by the time they arrive in the ED. Most Intensive Care Units will argue that the prognosis for recovery is extremely poor and often not accept the patient into the unit which is often very strapped for space.

    They usually end up counselling the family about the poor prognosis, and the long term suffering that they and their elderly relative will endure and counsel that a withdrawal of treatment is the most humane option available. The patient is then usually extubated in the ED and either dies shortly thereafter or is admitted to a general ward to live out their remaining hours.

    I think that what this researcher should be trying to say is that given that even if an elderly person is successfully resuscitated prior to hospital, the long term outcome is very rarely positive, therefore the money should be better spent of day to day care.

    This is something that I couldn't agree more with. I'd also take it a step further in that residential care facilities and general practitioners who look after these elderly people need to be more proactive in discussing with their residents and families in determining end of life care plans for them as to avoid this trauma of resuscitation, ambulance transport and then finally death in the ED when an event such as cardiac arrest, CVA, pneumonia etcetera occurs in later years.

  4. Yes. Kill them all. The unemployed, the disabled, anyone who is a burden on society. While we're there, put lots of defibs in Tesco's. But before using them check the patient's credit card and apply a charge before the treatment is given. Better still set up a scheme so everyone has to subscribe 10 per week to a 'Resus Plan' in case they have a cardiac in the supermart. Then we can bypass the credit card system because they are signed up to the plan. But make sure they are fully paid up of course. If for any reason the defib is used in error and the patient is not able to pay, inject them with 300ml of morphine. That will finish them off.Then use the money saved to pay the managers to spend more time on golf courses.

    BTW, in case anyone thinks I'm being serious, I'm just being cynical – or prophetic?

  5. well, I definitely think that once you've got to the point where a rescucitation attempt is going to be a painful and horrible thing, you should have the OPTION to say “do not rescusitate”. Personally, if I'm very old or suffering a terminal illness and it gets to that last moment and someone is in the room, I want them to hold my hand and let me go peacefully and with dignity, rather than hauling me out of bed, ripping my nightie off, and trying to drag my pulse back to my frail shell of a body for a few extra days or weeks.However that's MY take on it regarding MY life and others may feel differently. The default should certainly not be “leave them to die” and definitely not from a saving resources point of view.

    That's all I'm saying as I'm not allowed to get upset about the Daily Mail any more, it uses up too much energy in ranting.

  6. Exactly – you should have a *choice* – but having just read the article, the author thinks that it costs too much in resources to offer that choice, that it takes too much time to discuss this thing with patients – time which would be better spent doing other things.It seems that this idea wil take choice away from people.

    I won't be asking for CPR if I get too infirm – but I'd like it to be *my* choice, and not the choice of NICE (Clinical Excellence government bods).

  7. It really upsets me that older people are treated this way. In this country we don't allow euthanasia, but isn't this just euthanasia in fancy dress??

  8. I'm extremely disturbed by the suggestion that a do not resuscitate policy should be applied to people based on their demographic status rather than their individual health. “Likely low chance of success” is a consideration that needs to be applied to individuals, not social groups.Of course statistically speaking, elderly people in care homes are less likely to be successfully resuscitated. But that's like saying all children at a low-performing school should be automatically refused entry to Oxford or Cambridge because they're statistically less likely to get high exam results.

    Also, the default DNR policy being suggested is pretty hardline. While the authors seem to be suggesting there could be a right for patients to “opt in” to resuscitation rights, they aren't really – as the article makes quite clear, even if someone is capable of choosing resuscitation this could be refused on financial grounds. “Autonomy must be limited….by considerations of effectiveness and efficiency if treatment is funded through taxation.”

    I agree that if we are cutting off the option to resuscitate because of the statistical possibility of success, this ought to be mooted as a national policy for all out of hospital arrests. (And why would it not apply to in hospital arrests as well?)

    Personally I don't think it is ethically acceptable to make this decision on other peoples' behalf for financial and statistical reasons, but even if this were reasonable then it would be unjustifiable discrimination to apply that calculation only to elderly people in nursing homes.

  9. This is just plain ageism. They're going to have to stop calling them “care” homes, after everything I've read recently that's the last thing that happens in them.BTW – nice to have met you today Reynolds! Hope it wasn't too weird for you, I didn't really know what to say. Hope you didn't have too crappy a day in the car.

    🙂

  10. do you have access to an NHS computer? you should be able to apply for an athens account, and then you'll be able to read all these articles to your hearts contentsearch from the nhs website

  11. Medicine gone mad. When people *want* a peaceful death, they're not allowed to have it (at least on this side of the pond). When they're dying and need help, they're not allowed to have it, because it costs too much.

  12. Is the argument “people in nursing homes don't benefit from resus” actually aiming to highlight these practical deficiencies in nursing home care? Or is it just assuming poor quality care and lack of bystander CPR as an acceptable basic starting point, and saying that it's not worth funding any improvements in life support skills?

  13. there is some milage in what is being discussed here. whether we like it or not, we're all going to die. thats a given fact of life. i cannot condone euthanasia by default, this should be an allowed personal choice.however, the statistics in an NHS hospital, with full resus training and fully experienced resus teams are no better. the survival rates of having a cardiac arrest, being resusitated and walking out the door of an hospital aliive are also about 3-5%, despite what the daily mail may say. Adults usually have cardiac arrest for heart disease, when the heart has sustained serious damage or its just plain old and knackered.

  14. I'm a strong believer in the right of an individual and loved ones to opt for DNR if they have decided that's what they want – but the idea of a blanket decision is outrageous and frightening in an ageing population. In a few decades, as much as a quarter of the population will be classed as “old”, that's a lot of people walking around with the sword of damocles hanging oveer them. My gran is 84 years old. Yet she is enjoying life more than ever. I'm ashamed to say that her social life is better than mine! If anyone ever finds her facedown in the street, I hope she gets everything that modern medicine has to offer.

  15. I agree with your observations here Morticiah. Generally the low pay and low supervision makes for very poor care but, like you, I was very lucky to witness my Dad's final weeks of care in a Hospice which really couldn't have been better. Stunning contrast to what I was witnessing in a General Hospital where I was doing a clinical placement at the time. There was a man dying of the same condition as my Dad but their two experiences were so very different. I wish I could have swept him off to the Hospice.

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