At what cost are resuscitation discussions avoided in general practice?
Editor – Further to the assertion by Fritz et al (Clin Med Decem ber 2014, pp 571–6) that resuscitation, alongside overall goals of care, should be routinely discussed in clinical practice, the benefits of initiating discussions in the community warrant attention.
Deciding treatment priorities at the end of life requires space for deliberation. Particularly when acutely unwell or lacking capacity, it is not always possible for patients to engage with these discussions meaningfully in hospital. An equitable standard of care can only be achieved if end of life conversations and advance care planning are conducted routinely by GPs.
Most patients identified by GPs as nearing the end of life have not had resuscitation decisions documented; in 502 practices, only 20% of these patients had a community DNACPR form.1 Despite death being predicted, this can expose patients to unsuccessful paramedic resuscitation attempts in their final moments. Neither though should DNACPRs be misinterpreted to mean ‘do not admit to hospital.’ Reports suggesting paramedics feel they ‘cannot clinically help’ such patients, diverting ambulances elsewhere, are highly concerning.2 Contextualisation amid overall goals of care remains key; much can be learnt from the US experience of POLST.3
Are GPs reluctant to discuss end of life care? The national snapshot indicated that 58% of dying patients were offered this conversation, with 42% documenting their preferences.1 GPs report particular anxieties when mentioning resuscitation, often waiting until the patient's condition clearly deteriorates.4 This is problematic. Doctors are systematically overoptimistic when prognosticating in terminal illness, which may guide patients to request futile treatment options at the expense of optimal supportive care. Though challenging, resuscitation discussions are necessary in achieving a peaceful death.
Delegating additional, ostensibly bureaucratic, responsibilities to GPs is unlikely to be popular. Are such discussions a priority when practices already strain to deliver an escalating workload with limited resources? From crisis comes opportunity. Acute trusts are similarly struggling to manage their flow of frail elderly with increasingly complex needs. Upholding patients’ wishes at the end of life, with shared understanding between healthcare services – the best standard of care – could still prevent unnecessary hospital admissions. This would alleviate ssshealth budget pressures, releasing funding for reinvestment in general practice.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2015 Royal College of Physicians
References
- 1 .↵
- Omega – the National Association for End of Life Care
- 2 .↵
- BBC News
- 3 .↵
- 4 .↵
- Miller S
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