706 | Correspondence
Difficult decisions
P. A. Ward*
London, UK
*E-mail: patrickward81@hotmail.com
Editor—I read with interest the recent editorial by Brindley and
Beed1 on the importance of carefully considering the appropri-
ateness of cardiopulmonary resuscitation (CPR) in each patient
before attempting it. The authors draw a parallel between CPR
and the intensive care unit (ICU) and the capacity of each of
these interventions to cause more harm than good when
employed inappropriately. A further parallel can be drawn from
the relative absence of prior decision making in CPR/do not
attempt resuscitation (DNAR) situations that is often mirrored
in the ICU referral process. The decision whether to attempt
CPR can be extremely difficult, not least because it is dependent
upon a myriad of factors, much like the decision whether to
admit a patient to the ICU. It is therefore hugely surprising how
frequently both of these difficult decisions are considered for
the first time when the patients are in extremis (in often rather
stressful circumstances), and the decisions are invariably left
to anaesthetists/intensivists to make (usually on their first
encounter with the patient) rather than being made in advance
in a timely, considered fashion by the surgical or medical team/
Consultant responsible for the patient’s’ care. Indeed, an audit of
the ICU referral process at St Mary’s Hospital Adult Intensive Care
Unit, London (October 2012–January 2013) demonstrated that
none of the 22 patients (mean age 59 yr, range 23–88 yr) referred
to the ICU during this period had DNAR orders completed by their
responsible medical or surgical teams, and in only 9% of patients
had the referring team considered any limits of care.
Of course, there are some patients who experience a cata-
strophic decline or unexpected event that precludes such prior
decision making, but it is often possible in the vast majority of
patients requiring ICU admission/higher levels of care/CPR to
Do not resuscitate and the intensive care unit: time to talk
P. G. Brindley1, * and M. Beed2
1
Alberta, Canada, and 2Nottingham, UK
*E-mail: peter.brindley@albertahealthservices.ca
Editor—We sincerely thank Dr Ward for his interest in our
editorial1 and agree with his comments. For both intensive care
unit (ICU) admission and cardiopulmonary resuscitation (CPR)
there is an increasing presumption of maximal intervention
( just say ‘yes’), coupled with an increasing reliance on ICU practi-
tioners to become responsible for many discussions, decisions,
and deaths. Both cardiac arrest and ICU admission are usually
(though not always) presaged by gradual, recognizable, and
reversible physiological derangement. In-hospital cardiac arrest
may not always be avoidable, but is often associated with the
have identified the potential for clinical decline and predict the
need for escalation in treatment before the patient reaches ex-
tremis. This reluctance/failure of medical and surgical teams to
make these decisions on limits of care/DNAR orders may reflect
a failure to recognize clinical deterioration (critical care outreach
were involved in only three of 22 patients referred in the audit),
an unwillingness or unfamiliarity with making such difficult
decisions (the referral teams were unaware of premorbid func-
tion in 36% of the patients referred), an over-reliance upon critical
care colleagues, a fear of litigation, unrealistic expectations of
critical care (only 45% of the patients referred were accepted for
admission), or a desire to follow the path of least resistance
where everyone is considered a candidate for ICU admission
(and cardiopulmonary resuscitation). Regardless of the reason,
our medical and surgical colleagues should be encouraged to
take increased responsibility for these decisions and to consider
carefully the appropriateness of these interventions themselves
(with assistance/advice from the ICU where necessary) at the
earliest possible juncture; ideally, before they are prompted to
do so by their critical care colleagues at the inevitable cardiac
arrest call!
Declaration of interest
None declared.
References
1. Brindley PG, Beed M. Adult cardiopulmonary resuscitation:
‘who’ rather than ‘how’. Br J Anaesth 2014; 112: 777–9
doi:10.1093/bja/aev052
following factors: failure to discuss, failure to document, failure
to alert, failure to respond, failure to rescue, and even failure
to stop. Consideration of both ICU escalation and CPR status
should be considered earlier for deteriorating patients. Indeed,
the National Confidential Enquiry into Patient Outcome and
Death (NCEPOD) report goes further, and recommends that
resuscitation status be considered upon hospital admission for
all acutely ill patients.2
Resuscitation is central to modern acute care, and as such,
all practitioners (not only ICU practitioners) need a better

understanding of its nuances . . . and its limits. However, we also
need to reach out ( pre-emptively) to our non-ICU colleagues and
not criticize them for not knowing our specialty as well as us. It is
part of our job to emphasize that ICU works best when arresting a
patient’s deterioration, not when a deteriorated patient arrests.
With certain exceptions, CPR is often a last-ditch attempt. In con-
trast, ICU resuscitation (without chest compressions) affords the
possibility to revisit a patient’s trajectory after therapy (‘a trial
of life’). As such, it might be entirely appropriate to offer ICU ad-
mission and resuscitation (e.g. inotropes, mechanical ventila-
tion), whilst precluding chest compressions or defibrillation
should this fail. Several hospitals already use ‘goals of care’ or
‘ceiling of care’ documents. These allow ‘do not resuscitate’
(DNR) decisions to be considered separately from other, less
binary, escalation decisions (no more ‘all or none’).2 3 It also
emphasizes that DNR does not mean ‘do not respond’ or ‘do
not care’. It is prudent to set sail with an anchor.
Need for development of face-to-face orotracheal intubation
using direct (Macintosh) laryngoscopy
E. M. Rottenberg
Ohio, USA
E-mail: rottenberg.1@osu.edu
Editor—Zraier and colleagues,1 based on a previous study of face-
to-face orotracheal intubation (ftf-OTI) with a difficult airway
manikin placed in the sitting position facing the operator,2 pub-
lished a case series of patients intubated in the operating theatre
using the Video-Airtraq™ laryngoscope (VAL) in difficult circum-
stances using a ftf-OTI technique. They reported that the airways
of the seven [intubation difficulty score (IDS) >5] patients were
rapidly, easily, and safely secured using the VAL-ftf-OTI tech-
nique and suggested that intubation in the sitting position
is probably the safest position for airway management. They
reported that clinical trials evaluating VAL-ftf-OTI as a primary
airway management strategy are ongoing to confirm their obser-
vations. However, new evidence suggests that preclinical and
clinical trials of Macintosh Laryngoscope (ML) ftf-OTI and video
laryngoscopy (VL) ftf-OTI should also be included.
Schober and colleagues3 recently published a manikin simu-
lation study of ‘inverse intubation’ in entrapped trauma casual-
ties comparing ML-ftf-OTI, McGrath (McGrath, Aircraft Medical,
UK) VL-ftf-OTI, and VAL-ftf- OTI, with the manikin placed in a
sitting position with the neck immobilized and accessible only
from the left anterolateral side. They concluded that all three
techniques have a high success rate, but the usefulness of the
McGrath VL-ftf-OTI is limited because of the longer duration for
intubation. However, intubation was always successful and
Correspondence | 707
Declaration of interest
None declared.
References
1. Brindley PG, Beed M. Adult cardiopulmonary resuscitation:
‘who’ rather than ‘how’. Br J Anaesth 2014; 112: 777–9
2. Findlay G, Shotton H, Kell K, Mason M, et al. Time to intervene?
A review of patients who underwent cardiopulmonary resus-
citation as a result of an in-hospital cardiorespiratory arrest.
A report by the National Confidential Enquiry into Patient
Outcome and Death. NCEPOD, London 2012. [internet]. http://
www.ncepod.org.uk/2012report1/downloads/CAP_summary.
pdf [accessed Aug 20, 2013]
3. Dahill M, Powter L, Garland L, Mallett M, Nolan J. Improving
documentation of treatment escalation decisions in acute
care. BMJ Qual Improv Report 2013; 2: doi:10.1136/bmjquality.
u200617.w1077
doi:10.1093/bja/aev051
tended to be fastest with VAL-ftf-OTI, suggesting that this
technique may be a promising option. They suggested that
ML-ftf-OTI (or ‘inverse direct laryngoscopy’) showed reason-
able intubation times and, given the widespread availability of
Macintosh laryngoscopes, seems a useful technique.
Declaration of interest
None declared.
References
1. Zraier S, Bloc S, Chemit M, Amathieu R, Dhonneur G. Intub-
ation in the operating theatre using the Video-Airtraq™ laryn-
goscope in difficult circumstances by a face-to-face tracheal
intubation technique. Br J Anaesth 2014; 112: 1118–9
2. Amathieu R, Sudrial J, Abdi W, et al. Simulating face-to-face
tracheal intubation of a trapped patient: a randomized
comparison of the LMA Fastrach™, the GlideScope™, and
the Airtraq™ laryngoscope. Br J Anaesth 2012; 108: 140–5
3. Schober P, Krage R, van Groeningen D, Loer SA, Schwarte LA.
Inverse intubation in entrapped trauma casualties: a simula-
tor based, randomised cross-over comparison of direct, indir-
ect and video laryngoscopy. Emerg Med J 2014; 31: 959–63
doi:10.1093/bja/aev053