Chakraborty & Creaney (Psychiatric Bulletin, October 2006, 30, 376–378) described the understanding of ‘do not resuscitate’ (DNR) orders among staff in continuing care psychiatric wards. Many nursing staff and many psychiatric trainees connect DNR orders not only with cardiopulmonary resuscitation (CPR) but also with the intensity of medical intervention for physical illness. Deterioration of physical health is more common than cardiac arrest on old age continuing care psychiatric wards and requires a decision on whether or not to transfer to a medical facility. In the absence of clear guidelines, the role of DNR orders is debatable.
The argument for a DNR order is clear. In advanced dementia complicated by physical debilitation, CPR is unlikely to be successful. If successful, residual brain damage worsens the prognosis, contributing to an even poorer quality of life. Such information is understood by relatives. However, reasons given for not transferring to a medical ward appear vague and at worst inhumane to relatives. A common explanation from a medical registrar on duty is that further intervention is unlikely to improve quality of life. This is viewed by many relatives as evidence of ageism in an era of scarce resources. Indeed, transferring such patients may improve their quality of life by relieving pain and discomfort caused by reversible conditions such as pneumonia, septicaemia and bowel obstruction.
Perhaps the answer lies with clear and transparent guidelines supported by objective means of measuring quality of life. Old age psychiatrists need training in palliative care so that they can justify their treatment choices in those with terminal illness.
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