HEALTH / Second opinion

TALKING to someone about the possibility of their death is rarely easy for a doctor or for close relatives. Until quite recently, doctors mostly avoided the issue, arguing that patients did not want to be told that their illness was incurable - and they would insist that relatives kept up the deception. Couples were divided, one being told the truth and the other a falsehood. The two were, in effect, forbidden to talk about the most important event in their married lives.

Opinions have changed, however, largely because of campaigning by doctors and nurses working in hospices, who have shown that most patients dying from cancer prefer to be given truthful answers about the progression of their illness; that they can cope with this information; and that couples who are able to talk about the prospect of death often come closer together. Patients in hospital with heart disease, liver disorders or any serious illness are now generally given straight answers to straight questions.

Some other equally important aspects of death and dying in hospital are, however, still avoided or pushed into the background. One of these is the decision whether or not to attempt resuscitation when death occurs. Most hospitals now have a well organised system for dealing with a patient whose heart suddenly stops - the resuscitation team attempts to restart the heart and breathing. Plainly this cardiopulmonary resuscitation (CPR) makes no sense at all for someone with a progressive, fatal disease who had been told he or she was going to die soon, and in these circumstances the case notes may be marked 'do not resuscitate'.

The difficult question is whether the order not to resuscitate should be on the doctor's say-so, or whether there should be consultation with the patient and the family. Is resuscitation a right for every patient, no matter what the age or state of health? Most elderly people want resuscitation when asked. In some recent studies, more than three-quarters of people over 65 attending hospital outpatient clinics and between 43 per cent and 88 per cent of elderly hospital inpatients opted to be categorised as for resuscitation. In general, patients are much more likely to opt for resuscitation than either their doctors or their families.

Most people, however, have a quite mistaken impression of the effectiveness of CPR. For someone in hospital with an acute, recent illness whose heart stops, the chance of leaving hospital alive after CPR is 10 to 17 per cent, but in someone with a chronic illness the chance is less than 5 per cent and it goes down with age.

A study reported in the New England Journal of Medicine showed that half the patients who had opted for resuscitation changed their minds when their chances of survival were spelt out in detail. Only 6 per cent of people aged over 85 wanted to be registered as desiring CPR. This is an ethical issue that has little to do with money. A failed attempt at CPR does not add much to the cost of the final illness, but it may be distressing for other patients and for the family. Talking about the options should be included in any discussion between doctor and patient about the likely outcome of treatment for any serious illness.