I want to open this by saying that what follows is based on opinions, it is not representative of NHS policy at present. So please, bear this in mind when reading and replying. I was sat in a meeting recently during which an accident and emergency consultant gave a presentation on a number of things of interest to GP practices. Towards the end of her piece she turned to the 'future' and presented an idea which whilst not new I'd be really interested to hear your views on. It's used already in Australia amongst other places and it takes the form of some advanced care planning but has implications for us all. The talk was on ceilings of care, a predetermined highest level of intervention by a medical team. It was presented as a grid which I'll struggle to replicate here but it had 4 categories on the x-axis and 4 on the y-axis. On the y axis were 4 very broad definitions of levels of care: 1.Full invasive intervention and referral / transport to national centres of excellence. (Example is during the swine flu outbreak when some people were put on external ventilation to allow their lungs to recover) 2.Up to and including intensive care at the district general hospital. 3.Ward based care (but no further). 4.Care at home / residential or nursing home. Onthe x axis were four very broad definitions of a person’s state of general health. 1.Normally very fit and well. 2.Some co-morbidity / chronic health conditions (COPD / diabetes / morbid obesityetc) 3.Generally poor health, multiple chronic illnesses and or co morbidities. 4.End of life / palliative care. The plot showed how each level of care might be made available to people in each category and of course this would not be a decision taken lightly but in the presence of the patient / family / multi disciplinary team. It's perhaps unsettling to think that a medical team will, based on your other conditions and general health predetermine at what point they're going to limit their intervention but it seems to be well backed up. The crux of it was very simple: if, based on good science, your chances of meaningful survival with a good quality of life are high then the teams will move heaven and earth, however, if you were less likely to survive then you would be lower down the scale. I'll endeavour to get the references for some of the information below when I'm not reliant only on my phone. It's been shown recently that 63% of us will die in hospital, if you're male then that probability is even higher (females tend to live longer and are more likely to pass away in a residential home / nursing home etc). It's also been shown that for a chronically unwell elderly person, their chance of surviving a CPR attempt without brain damage is just under 2%. Compare that with an otherwise fit and well person whose long term survival chances are around 15% if the arrest is witnessed in a clinical setting and immediately resuscitated. So, there's an opportunity for a decision to be made somewhere as to how far we want a medical team to go or, in fact, how far they should go in the knowledge of the above. It's worth noting at this stage that CPR is violent, invasive and painful and not the sanitised process we see in films or on TV where after a few compressions the patient sits up, thanks the team for their help and goes about their day. Infact, the consultant likened her crash team to a 'pack of attack dogs' who pounce on a patient literally jumping on their chest so vigorously that cracking ribs isn’t unusual whilst others intubate, take arterial blood for gas analysis and so on. She asked if that was how the audience would like to spend their own last hour or indeed that of an elderly loved one. Would it not be better, more dignified perhaps, for that elderly relative to spend their final moments in the comfort of their own space maybe with their family nearby? If the discussion and decision had taken place before the crisis had occurred then would the family member know that the person didn't want an ambulance to be called and have two ambulance crew jumping on them followed by (and I use her words, not mine) a team of ED attack dogs? People’s plans can and do change, especially in a crisis where the prospect of losing your own life or that of a loved one can have a significant impact on decision making ability; so, is having something like the chart I alluded to above in the open, for all to be aware of a bad thing? Perhaps it is, or perhaps not? This is where I’m really interested to hear your views.