LETTERS * CORRESPONDANCE

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Resuscitation of the elderly and the terminally ill P5 hysicians using two hospitals with which I have been associated are finding the recent article by Murphy and associates' and the accompanying editorial by Podrid2 informative and relevant. The article reports the outcomes of cardiopulmonary resuscitation (CPR) in 503 consecutive elderly patients (aged 70 years and over) at five Boston health care institutions: two acute care hospitals, two chronic care hospitals and one long-term care institution. CPR was rarely effective for those with cardiopulmonary arrest that had occurred out of hospital,

was unwitnessed or was associated with asystole or electromechanical dissociation. Only 3.8% survived to hospital discharge, and most survivors had had ventricular arrhythmias. These and other outcome features led Podrid to conclude that CPR in the elderly is a blessing for a few but a curse for most patients and their families. Recent contributors to CMAJ have concluded that CPR is rarely effective for the terminally ill3 or for residents of long-term care institutions.4 Several others57 agree that CPR is sometimes medically contraindicated for the terminally ill and in that situation should not be offered during discussions of do-not-resuscitate orders with the patient or the family. The CMA's position on resuscitation of the terminally i18,9 requires consent by the patient, or by the family if the patient is incompetent, before the attending physician writes a "No resuscitation" order. This regulation means that if the heart stops a patient will automatically receive CPR unless this treatment was rejected in a previous conversation.3 No place is left for resuscitation to be withheld solely because it is medically contraindicated. One Canadian medicolegal authority'0 states that "care that appears unlikely to be of assistance may be offered, such as life support for a terminally ill patient, but it may legitimately be withheld if it is considered futile." It is time the CMA revised its position on resuscitation of the terminally ill and affirmed that resuscitation may be withheld simply because it is considered

futile. However, this policy change would not, in my view, remove the attending physician's responsibility to share his or her reasons for considering CPR medically contraindicated if this information were sought by the terminally ill patient or the patient's legal guardian. William I. Morse, MD, CM, FRCPC Consultant in internal medicine

(palliative care) Fisherman's Memorial Hospital Lunenburg, NS

References 1. Murphy DH, Murray AM, Robinson BE et al: Outcomes of cardiopulmonary arrest in the elderly. Ann Intern Med 1989; 111: 199-205 2. Podrid PJ: Resuscitation in the elderly: A blessing or a curse [EJ? Ibid:

193-195 3. Buckman R, Senn J: Eligibility for CPR: Is every death a cardiac arrest? Can Med Assoc J 1989; 140: 10681069 4. Fisher RH: Do-not-resuscitate orders and long-term care institutions [E]. Ibid: 793-795 5. Walker I: Resuscitation of the terminally ill [C]. Can Med Assoc J 1990; 142: 531-532 6. Morrin PAF: Resuscitation of the terminally ill [C]. Ibid: 1036-1037 7. Baylis FE: Resuscitation of the terminally ill [C]. Ibid: 530-531 8. Resuscitation of the terminally ill. Can Med Assoc J 1987; 136: 424A 9. Joint statement on terminal illness: a protocol for health professionals regarding resuscitative intervention for the terminally ill. Can Med Assoc J 1984; 130: 1357 10. Dickens BM: Terminal care and related decisions. A review of legal developments. Mod Med Can 1990; 45: 296-306

[The CMA responds.: Dr. Morse's letter is very timely indeed. The Committee on Ethics of the CMA is reviewing the matter, with an eye to suggesting apCAN MED ASSOC J 1991; 144 (7)

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Resuscitation of the elderly and the terminally ill.

LETTERS * CORRESPONDANCE We will consider for publication only letters submitted in duplicate, printed in letterquality type without prDportional spa...
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