Ed i to r ia l

End of life decisions and care of the elderly

There is increasing concern amongst those involved

with care of the elderly not only in the community

but also in residential and nursing homes, as well as

the elderly themselves. Recent investigations and

reports have highlighted that many older people

are being neglected and poorly treated to the extent

of almost being second-class citizens. One of the

main issues raised was the lack of consultation,

with the vast majority of older people stating that

their views had not been sought. In addition, there

was little or no evidence of their involvement in

the design of services and as a consequence these

services were not tailored to their requirements

even though they are the biggest users of health

care systems, occupying around two-thirds of hos-

pital beds. The really sad aspect also identified was

the fact that 80% did not think that their views

would influence the planning of services anyway.

Unfortunately various government policies, which

set targets for health care professionals were lead-

ing to the rushed discharge of older patients and

there were concerns about inconsistencies in

community rehabilitation of stroke patients. How-

ever, one area of real progress was that steps had

been taken to address age discrimination in public

services and more people were being supported to

allow them to live at home.

Many older people guard their independence

jealously and want to remain in their own homes

surrounded by things that are familiar. Unfortu-

nately this means that there are increasing num-

bers living alone particularly the ‘oldest old’ – those

over 85 years old and these are more likely to be

women. As we all are aware this is the fastest

growing age group in many industrialised coun-

tries. Only those with long standing illnesses were

most likely to be living with family but there was

evidence that this placed an enormous strain on

personal relationships. The charity, Help the Aged,

has found that television is the main source of

company for nearly half of all over 65s, more than

a half did not see their family more than once a

month, with only 8% seeing their grandchildren

once every 6 months. There was also a reluctance

to ask to see their relations more often out of fear of

‘pestering’ their family. In 2002, the Scottish Exe-

cutive introduced a policy of providing free

personal care for the elderly and now more than

40 000 receive this, whilst 9000 receive the benefit

in a care home setting. The cost of this has now risen

to over £200million and there are concerns that this

funding will be capped, meaning the contribution

by the older adult or their relatives will increase.

Examples of this have already been highlighted

with approximately half the local councils intro-

ducing waiting lists for free personal care with the

policy only being implemented after the individual

has been in a nursing home for more than 90 days.

There is considerable discussion regarding the

level of care provided for older adults, with con-

cerns that many end up dying undignified deaths.

Many health care workers have raised the issue

that their places of work have no end-of-life poli-

cies, they lack the training and support and some

struggle to cope with dying patients. As a result an

End-of-Life Care Programme has been introduced

which aims to reduce the number of emergency

hospital admissions so that many elderly people can

spend the last part of their life at home, with friends

and relatives, as they wish. By the end of 2005,

60% of hospitals, 28% of doctors and 47% of

hospices had introduced the programme but only

1% of care homes had complied. In addition, it was

admitted by health professionals that elderly

patients with cancer, heart disease or dementia

received poorer care than that provided for

younger patients with similar conditions, and that

dementia, arthritis and sensory impairment were

often overlooked. These issues have also been

highlighted by a paper published in a recent issue

of the British Medical Journal (BMJ 2006, 332: 479–

482) by S.P. Conroy et al. who question the current

NHS guidelines for cardiopulmonary resuscitation

in a continuing care setting. They state that the

potential benefits of resuscitation and the likeli-

hood and failure of adverse effects are not the same

for everyone and staff could be diverted away from

core elements of care, for limited benefit. They also

report that although there is limited information on

survival rates from cardiopulmonary resuscitation

in nursing homes in the UK, data from the United

States show a survival to discharge rate of 0–6%.

The baseline 1 year survival rate is 66% for people

in UK residential homes and <50% for those in

nursing homes. They also suggest that other factors

such as no bystander cardiopulmonary resuscita-

tion, unwitnessed cardiac arrest or type of arrest,

increasing age or arrival of ambulance may indicate

outcomes at the lower end of the range. They

conclude that resuscitation will be unsuccessful in

most old people in care homes, the cost of provi-

ding resuscitation to all requires scrutiny and the

� 2006 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2006; 23: 65–66 65

presumption of intervention is inappropriate when

treatment is unlikely to be successful. Therefore

they propose that the current guidelines should be

reviewed with two possible approaches; firstly at

institutional level and secondly with the individual.

The first has obvious implications for training and

resources as well as raising public awareness of the

ethical issues involved. In the second, the older

person and relatives would be involved in the

decision-making process, having had the situation

fully explained by health care professionals. The

individual themselves may also state that they do

not want to be resuscitated should the situation

ever arise. This report seems to have raised signi-

ficant issues for various care groups, with one sta-

ting that the proposal ‘smacks loud and clear of

ageism’ and that ‘it is unethical.…that there should

be blanket removal of resuscitation protocols from

care homes simply because they might not work’.

Careful evaluation of the publication elicits that

this is not in fact what they are proposing and in

fact suggest a seven-point checklist for the patient’s

best interests, which has to be completed. How-

ever, the key issue, from an ethical point of view is

that the decision to resuscitate or not should be

based solely on an individual’s need or wishes,

irrespective of age.

Discussion has also been raised regarding the

issue of ‘living wills’ with an act, coming into force

in England and Wales in April 2007, laying out a

statutory framework. Under the new Mental

Capacity Act, the code sets out how capacity should

be assessed, how advance directives on treatment

will operate and how decisions about treatment

should be taken once the act is in operation.

C. Dyer (BMJ 2006, 332: 623) reports that these set

out a patient’s wishes about possible future treat-

ment and come into play if the patient becomes

incapacitated. There have been some grave mis-

givings in the press and in a bid to defuse such

concerns, the code points out that relieving suf-

fering by causing death must not be a motivation

for treatment decisions. Also, doctors cannot be

obliged to sustain life, such as hydration and arti-

ficial nutrition if they believe it to be against the

patient’s best interests, even if requested in a living

will.

On the Continent, the situation is slightly dif-

ferent with the Netherlands legalising euthanasia

in 2001 and Belgium in 2002. However, in the

latter, the current law requires that patients have to

be in full possession of their mental powers before

they can consent. It is interesting to note that many

people believe that euthanasia or assisted suicide

has been legalised in Switzerland. In fact, this is

untrue but there is no prosecution if the person

assisting the suicide or death successfully claims

that he or she is acting unselfishly and also that

person need not be a medical professional. Unlike

the Netherlands or Belgium there is no illusion in

Switzerland that assisted suicide is a medical prac-

tice. This topic and the ethical and moral issues

associated with it will fuel debate for many years

but the situation, one way or another, will need to

be addressed in the broadest context.

It is silliness to live when to live is a torment:

and then have we a prescription to die when death is our

physician.

Othello Act 1 Sc 1

James P. Newton

Editor

� 2006 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2006; 23: 65–66

66 Editorial