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Ethical, professional, and legal obligations in clinical practice
  1. A K Jain,
  2. I Chattopadhyay,
  3. A Kallat
  1. Department of Medicine for the Elderly, Wrexham Maelor Hospital, Wrexham LL13 7TX, UK;
  1. dralokjain{at}netscapeonline.co.uk

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We wish to applaud Mr Gore on conducting sessions and writing about ethical, professional, and legal obligations in clinical practice.1–3 It is an area in which most doctors fail to get training at an earlier stage, and there is a case for other specialties to take heed from Gore's series and conduct such educational exercises in their hospitals.

We agree with Gore that doctors tend to underestimate how willing people are to talk about their own death3 and, in fact, their resuscitation status. As doctors we tend to assume that this discussion with patients (where feasible) would upset them enormously and hence the reluctance to discuss it with them.

To find an answer to this dilemma, we conducted an interview based study in our district general hospital, where 70 inpatients on medical wards were interviewed to assess their knowledge of cardiopulmonary resuscitation and their views on getting involved in their “not for resuscitation” (NFR) decision. The group had equal number of male and female patients and equal number of patients below and above the age of 70 years. The results were very interesting and showed that majority (∼71%) of the hospital inpatients wished to get involved in the discussion related to their NFR decision. This view was similar among young and old patients. This sends a strong message that ethically we ought to involve mentally competent patients in their NFR decisions if the latter so wish.

We disagree with Gore that resuscitation be offered if it is specifically requested by a patient even if a successful resuscitation is unlikely.3 In patients in whom cardiopulmonary arrest clearly represents a terminal event in their illness, attempted resuscitation might be considered inappropriate. Neither patients nor their relatives can demand treatment that the health care team judges to be inappropriate.4 There are situations where medical reality and patient's expectations in relation to their illness and NFR decisions do not match.5 In situations like these the healthcare team has the moral and legal responsibility to help their patients reach a decision in their best interest.

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Author's reply

I welcome the comments of Dr Jain and his colleagues. The apposite study which they conducted at Wrexham Maelor Hospital demonstrates the desire among patients, young and old, for involvement in NFR decisions. As doctors we must confront our own unease at discussing matters of resuscitation and death with patients.

I accept the authors' reservations about my endorsement of compliance with a patient's wish for cardiopulmonary resusciation in all cases. In many such cases cardiopulmonary resusciation would be medically inappropriate, and it is indeed the responsibility of the healthcare team to counsel the patient accordingly. Nevertheless the series of discussion articles was geared towards education for junior medical staff, and I chose to keep the guidelines straightforward with an emphasis on patient autonomy. Certainly in any such situation one would expect a more senior member of the healthcare team to identify and address that mismatch between medical reality and patient/relative expectation. Counselling might then be offered in the hope of reaching consensus on the suitability of a NFR decision.

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