for the use of a fibreoptic bronchoscope passed through an endotracheal tube, "even if the patient is still actively bleeding." One of the problems in severe haemoptysis is the rapid formation of clots which can obstruct main or lobar bronchi completely and can be removed only through a wide bore (5 mm) aspirating tube or by grasping forceps. Thus the use of a rigid bronchoscope is not an outdated tradition, as the authors imply, but a lifesaving necessity. Some of my most alarming experiences when treating severe intrabronchial bleeding akin to massive haemoptysis have been after bronchial or transbronchial biopsy during fibreoptic bronchoscopy. Vision was immediately lost, the narrow suction channel rapidly became blocked, and prompt use of a rigid bronchoscope under intravenous anaesthesia with oxygen injection ventilation was needed to avert death. When haemoptysis is not copious, or when it is subsiding, fibreoptic bronchoscopy is preferable to rigid bronchoscopy in finding the source of bleeding and determining its cause. In the presence of massive haemoptysis, however, even in the restricted sense defined by the authors, an operator skilled in the use of the rigid instrument must be readily available if deaths are to be prevented. This is one setting in which the rapidly diminishing number of respiratory physicians trained in rigid bronchoscopy is a cause for concern. IAN W B GRANT

Kirknewton, West Lothian EH27 8EA I Jones DK, Davies RJ. MIassive haemoptvsis. B3rMedJ 1990;300: 889-90. (7 April.)

AUTHORS' REPLY,-We are pleased that Dr Grant agrees that, usually, massive haemoptysis will settle spontaneously. Most patients with massive haemoptysis will present initially to hospitals without the facilities or staff to undertake rigid bronchoscopy or cardiothoracic surgery. Lives will be saved if doctors protect the airway, give adequate suction, correct hypoxia, replace blood loss, and treat any reversible cause of haemoptysis. Bleeding will cease eventually, and thus hasty transfer of patients to another hospital for emergency surgery is inappropriate. We agree that a rigid bronchoscope may be useful in a minority of patients. In the face of massive haemorrhage, however, neither a rigid bronchoscope nor a fibreoptic bronchoscope will locate the site of bleeding, although the rigid instrument may be better for determining which lung the blood is coming from. The formation of clots in the bronchi of the non-bleeding lung will generally be avoided if the patient lies head down and adequate suction is used. The formation of clots in bronchi leading from the bleeding site will arrest the haemorrhage and obviously these should not be removed. Removal through the rigid bronchoscope may be carried out later if appreciable lobar collapse persists. D KEVIN JONES ROBERT J DAVIES Department of Respiratory Mceiciltc, St Bartholomew's Hospital, ILondon ECIA 7BE

Mortality in elderly patients admitted for respite care SIR,-We share the concern of Dr Sheila Howarth and colleagues' about a 13% mortality2 among elderly patients within two weeks of admission to hospital for respite care and within three weeks of admission for social reasons. It is, however, misleading to suggest that DeLargy reported similar outcome figures.4 Although he reported 24 deaths in 100 patients admitted to his regular relief scheme for 18 weeks, overall mortality was

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30% in 18 months. This is probably considerably lower than the mortality recorded by Dr Howarth and colleagues, which we believe to correspond to an annual mortality of approximately 40%. In our own study of 243 admissions for 64 patients having regular respite care we reported a mortality in hospital of 10-2 deaths per 10000 person days and at home of 7 7 deaths per 10000 person days, with an overall annual mortality of approximately 30%.' These data emphasise the high mortality such patients have, whether at home or in hospital, and why length of stay, among other factors, is important in comparative audit of mortality in the elderly. Nevertheless, we agree wholeheartedly that the small increase in mortality in hospital should not discourage informed patients and their carers from seeking respite care if alternative support in the community is inadequate or unavailable. P M McCAFFREY

l1urgan Hospital, Lurgan, Co Armagh D H GILMORE T R 0 BERINGER

Royal Victoria Hospital, Belfast BT12 6BA I Howarth S, Clarke C, Bayliss R, Whitfield AGW, Semmence J, Healy MJR. Mortality in elderly patients admitted for respite care. BrMedJ 1990;300:844-7. (31 March.) 2 Rai GS, Bielawska C, Murphy PJ, Wright G. Hazards for elderly people admitted for respite ("holiday admissions") and social care ("social admissions"). BrMedJ 1986;292:240. 3 Rai GS, Bielawska C, Murphy PJ, Wright G. Hazards for elderly people admitted for respite and social care. Br Med J

1986;292:482. 4 DeLargy J. Six weeks in: six weeks out. Lancet 1957;i:418-9. 5 AlcCaffrey PM, Gilmore DH, Beringer TRO. Mortality in the elderly during respite hospital care. Ulster Medical _ournal 1989;58: 131-3.

Resuscitation decisions in a general hospital SIR,-I am in general agreement with Dr Kevin Stewart and colleagues' but take issue with them over their view that "documentation of the reason behind a decision not to resuscitate is not necessarily required." I also think that their proposed "ideal protocol" enshrines an important ethical fallacy: that patients and their relatives should always be involved when a "Do not resuscitate" decision is to be made. Patients and relatives should be involved when an assessment of the patient's quality of life is central to the decision.2 Such an assessment can be valid only if it is the patient's, who is, in effect, exercising his or her right to accept or decline treatment. There is, however, an important circumstance when it not only is unnecessary but may be harmful to seek patients' or relatives'' ews on a decision not to resuscitate-that is, when an attempt at resuscitation can have no reasonable chance of conferring medical benefit.2 This is a common situation in medical and geriatric wards and would have applied3 to at least 34 of the patients in whom Dr Stewart and colleagues reported a do not resuscitate decision to have been made and to all 15 whom they thought should not be resuscitated but in whom no decision had been made. Concerning patients and their relatives in such cases risks raising false hopes of prolonging life.' Furthermore, patients may suffer psychological harm after the discussions,4 and I suspect that psychological harm may also be done to relatives, particularly those of geriatric patients, in whom feelings of guilt and ambivalence are common. I believe such harm can be avoided only if the implication of each decision not to resuscitate and the reasons behind it are clearly thought through and documented. I suspect that the authors' contradictory statements concerning documenta-

tion of the reasons for a decision not to resuscitate reflect a failure to do this with which many of us can identify. S A BRUCE

Department of Medicine for the Elderly, St Helen's Hospital, East Sussex TN35 5AH I Stewart K, Abel K, Rai GS. Resuscitation decisions in a gencral hospital. Br MedJ7 1990;300:785. (24 March.) 2 Tomlinson r, Brody H. Ethics and communication in do-notresuscitate orders. N EnglI7 Med 1988;318:43-6. 3 Blackhall Lj. Must we always use CPR? N fEngl J Med 1987;317: 1281-5. 4 Schade SG, Muslin H. Do not resuscitate decisions: discussions with patients. I Med Ethics 1989;15:186-90.

SIR,-The policy advocated by Dr Kevin Stewart and colleagues that patients and their relatives should routinely be involved in the decision whether or not to resuscitate' potentially could lead to an increase in the number of inappropriate attempts at cardiopulmonary resuscitation. Previous studies have shown that elderly patients are in favour of resuscitation in circumstances which Dr Stewart and colleagues feel to be inappropriate-namely, malignancy and stroke. In the study by Gunasekera et al 49-2% of such patients were in favour of resuscitating elderly patients who were "severely and permanently physically disabled."2 Likewise, Shmerling et al found that 28% of patients would want cardiopulmonary resuscitation even if they had terminal cancer.3 This same study found that 41% wanted cardiopulmonary resuscitation to be performed for irreversible heart failure and 25% wanted it for irreversible coma. These findings suggest that patients have unrealistic expectations of the effectiveness and success of cardiopulmonary resuscitation. The reality is that less than 15% of people who have a cardiac arrest survive to discharge.4 Furthermore, a recent study by Taffet et al suggested that the prospects in the elderly are particularly dismal as no one over the age of 70 survived to discharge.3 These studies showed that cardiopulmonary resuscitation in patients with conditions such as cancer, stroke, sepsis, and gastrointestinal haemorrhage (conditions with which the elderly frequently present) was almost invariably unsuccessful. The glimmer of light in an otherwise bleak picture is that cardiopulmonary resuscitation is effective after cardiac events, especially if there is a closer degree of monitoring available than is found on general wards.6 Unfortunately, the elderly are often barred from coronary care or high dependency units because of their age, and such discriminatory policies should be reviewed. Discussing decisions about resuscitation is theoretically a step forward, but there is a danger that patients will be offered and may try to grasp a treatment that will not benefit them and hence will lead to inappropriate resuscitation attempts, which will deny them a more dignified death. N J DUDLEY

Department of Medicine for the Elderly, St James's University Hospital, Leeds LS9 7TF I Stewart K, Abel K, Rai GS. Resuscitation decisions in a general hospital. Br Medj 1990;300:785. (24 March.) 2 (iunasekera NPR, Tiller DJ, Clements LTS-J, ei al. Elderly patients' views on cardiopulmonary resuscitation. Age Ageing

1986;15:364-8. 3 Shmerling RH, Bedell SE, Lilielfeld A, et al. Discussing cardiopulmonary resuscitation: a study of elderly outpatients. J Gen Intern Med 1988;3:317-21. 4 Bedell SE, Delbanco 'FL, Cook EF, et al. Survival after cardiopulmonary resuscitation in the liospital. N Engl lMlled

1983;309:569-76. 5 Taffet GE, Teasdale TA, Luchi RJ. In-hospital cardiopulmonary

resuscitation.J.AMA 1988;260:2069-72. 6 Bayer Al, Ang BC, Pathy MSJ. Cardiac arrests in a geriatric unit.

Age.4geing 1985;14:271-6.

SIR,-While we agree with Dr K Stewart and colleagues that a definite decision about resuscita-

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