Scale of levels of care versus DNR orders.

I n his paper, which we read with interest, Cherniack argues that there is a worldwide increase in the use of do not resuscitate (DNR) orders in the care of the elderly. As geriatricians in an emergency department and a geriatric department we are concerned by this important ethical topic, and we understand that this increase is a reflection of the demographic increase in frail very old persons. The elderly must be offered the best care, and age as such should not be used as a decision criterion in order to exclude them from the best care. Nevertheless, care which is believed to be harmful and treatments which are considered futile must not be offered, and in some circumstances must not even be discussed. In the setting of the care of the frail elderly, we believe the use of simple DNR orders to be inappropriate and restrictive, because they fail to outline the kind of care and the extent of the care that the patient actually needs. We prefer a more nuanced approach based on a scale describing positively the contents of care at four different levels: terminal, palliative, usual, and intensive, only the last to include cardiopulmonary resuscitation (CPR). Perhaps a more positive formulation of such orders, as presented here, may contribute to changing attitudes and thus reduce the risk of ‘‘abandonment of the patient’’, which is potentially linked to the increasing use of simple DNR orders. Accordingly, we want to make several additional comments and one suggestion about the use of DNR orders in the care of the elderly.