Dilemmas in decision-making about resuscitation--a focus group study of older people

Cardiopulmonary resuscitation (CPR) may be used by default on patients suffering a cardiac arrest in hospital in the UK unless there is an order that specifies otherwise in the patient's notes. Guidelines recommend that the decision involves competent and willing patients or, in the case of incapacitation, their families. In practice, patient autonomy is often compromised. Ideally, discussion of preferences for end-of-life care should take place prior to hospitalisation. The majority of research on this topic has been conducted on hospitalised patients, so little is known about the views of older, but healthy, people about resuscitation decision-making. The present study was designed to address this gap. A series of eight focus groups involving a total of 48 participants over the age of 65 was conducted to explore people's views about the factors guiding resuscitation decision-making. A qualitative analysis, which emphasised the dilemmatic nature of resuscitation decision-making, identified two broad thematic dilemmas that subsumed six specific themes which contribute to resolving the dilemmas: quality of life (medical condition, mental versus physical incapacity, age and ageing, and burden), and the involvement of others (doctors and families) versus loss of autonomy. The dilemma underlying quality of life is that an acceptable quality of life after CPR cannot be assured. The dilemma underlying the involvement of others is that individual autonomy may be lost. The themes and subthemes provide the basis for guiding these difficult discussions in advance of serious illness.