Barriers to involving older people in their resuscitation decisions: the primary-secondary care mismatch highlights the potential role of general practitioners.

BACKGROUND: 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) orders are made frequently for older people in hospital. Sensitive anticipatory discussion is encouraged where possible, but usually this does not happen, despite the evidence suggesting that many older patients would like to be involved in such decisions.
METHODS: Current clinical practice in both primary care and secondary care and perceived barriers to patient involvement in resuscitation decisions was assessed using a questionnaire in Medicine for the Elderly physicians in two hospitals, and General Practitioners of teaching practices in Norfolk.
RESULTS: Response rate was 51% (n = 24/47). Hospital-based clinicians made DNACPR decisions more frequently, but discussed decisions with patients in less than 25% of cases. By contrast, GPs thought that patient involvement was more important and felt that they had a better understanding of the patient's wishes due to the long-term relationship they shared. Mental capacity was seen as the biggest barrier to patient involvement by both groups. Other barriers included lack of understanding, communication difficulties and practical concerns.
CONCLUSION: Further support and training could help clinicians improve their resuscitation decision-making practice. Advanced discussion in Primary Care with older people before they lose capacity may have a role in increasing their involvement in resuscitation decision making.