If you are old, ill-kempt or malodorous, try to spruce up before getting treated for a heart attack at a US emergency room. Stefan Timmermans reports on the social prejudice that can determine if you live or die

In 1967, sociologist David Sudnow offered the following advice:

"If you anticipate having a critical heart attack, keep yourself well-dressed and your breath clean." Sudnow was the first to reveal that whether a patient in the United States lives or dies depends upon the emergency department staff's interpretation of his social status. "Two people in similar physical condition may be differentially designated dead," Sudnow explained. "A young child was brought into the ER with no registering heartbeat, respirations or pulse and was, through a rather dramatic stimulation procedure involving the coordinated work of a large team of doctors and nurses, revived for a period of 11 hours. On the same evening, shortly after the child's arrival, an elderly person who presented with the same physical signs arrived in the ER and was almost immediately pronounced dead, with no attempts at stimulation instituted."

Because Sudnow's research took place before the advent of modern resuscitative care, people in emergency medicine believe that his analysis is now out of date. So, when I asked for permission to observe resuscitative efforts in a US hospital's emergency department, the head of the hospital's human subjects committee agreed, saying: "There is nothing to it. We just follow the protocols."

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When I eventually began research in two emergency departments, it became apparent that deciding life and death during resuscitative attempts was more complicated than the protocols suggest. For a start, almost nobody survives. I watched 112 attempts to resuscitate patients. Eleven were in a stable condition by the end of the attempt, but only one actually walked out of the hospital and several died a couple of days later. My study is not exceptional. The American Heart Association estimates that "no more than 1 per cent to 3 per cent of victims live to be discharged from the hospital. The true percentage is probably even less."

How social factors influence attempts to resuscitate someone was best demonstrated not by success or failure rates but by watching the fervour with which medical staff tried to revive different patients. Some patient characteristics turn their efforts either into a hectic medical intervention or into a slow, "going through the motions but not really trying" event.

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Generally speaking, the older the patients, the less aggressive were the attempts to save them. A physician noted: "You are naturally more aggressive with younger people. If I had a 40-year-old who had a massive MI (myocardial infarction), I would be very aggressive with that person. I suppose for the same scenario in a 90-year-old, I might not be." Medical effort was greatest with children. According to a nurse, dying children "go against the scheme of things. Parents are not supposed to bury their children, the children are supposed to bury their parents."

Patients with a high position in the community were also deemed worthy of effort. In one hospital, a well-liked senior hospital employee was being resuscitated. Asked how this effort differed from others, a respiratory therapist replied: "I think the routines and procedures were the same, but the sense of urgency was greater, the anxiety level was higher. We were more tense. It was very different from, say, a 98-year-old from a nursing home."

When Princess Diana died in a car accident, physicians tried external and internal cardiac massage for two hours although her pulmonary vein had been lacerated. A chief trauma physician admitted that "most other patients would have been declared dead at the scene or after arriving at the emergency department. But with a patient as famous as Diana, trauma specialists understandably want to try extraordinary measures".

When the perceived social viability of the patient is high, the staff will go all out to reverse the dying process. In the average resuscitative effort, four to eight staff members are involved. In the effort to revive a nine-month-old baby, however, I counted 23 health-care providers in the room at one point. Often the physician will establish a central line in the patient's neck, and respiratory therapists will check and recheck the tube to make sure the lungs are indeed inflated. These tasks are part of the protocol, but are not always performed as diligently in most resuscitative attempts.

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At the bottom of the moral hierarchy are patients for whom death is considered a "just punishment" or a "welcome friend". Death is considered a "blessing" for seriously ill or very old patients. A nurse assumed that old people had nothing more to live for, "When people are in their seventies and eighties, they have lived their lives," she said. The staff considered death an "appropriate" retaliation for drunks and drug addicts. I watched a resuscitative attempt for a patient who had overdosed on heroin. The team went through the resuscitation motions without much vigour or sympathy. Instead, staff wore two pairs of gloves, avoided touching the patient, joked about their difficulty inserting an intravenous line, and said how they loathed to bring the bad news to the patient's belligerent "girlfriend".

Patients at the bottom of the social hierarchy were often declared dead in advance. In a typical situation, the physician would tell the team at 7.55 that the patient would be dead at 8.05. The physician would then leave to fill out paperwork or talk to the patient's relatives. Exactly at 8.05, the team would stop the effort, the nurse responsible for taking notes would write down the time of death, and the team would disperse. In two other resuscitative efforts, the staff called the coroner before the patient was officially pronounced dead.

The power of social classification is most obvious when an elderly or seriously ill patient unexpectedly regains a pulse. This development poses a dilemma for the staff: are we going to try to save this patient, or will we let the patient die? In the drug overdose case, a monitor registered an irregular heart beat, but the physician in charge dismissed this observation with, "This machine has an imagination of its own." Staff who noticed signs of life were considered "inexperienced", and I heard a physician admonish a nurse who noticed heart tones that "she shouldn't have listened". Signs that could not be dismissed easily were explained as insignificant "reflexes" that would soon disappear.

After 25 years, Sudnow's observations still ring true. The social value of a patient affects the fervour with which the staff will engage in a resuscitative effort, the length of the effort and probably also the outcome. Because most social factors are unchangeable, it seems little can be done to avoid social rationing of this medical care.

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However, I did notice that when relatives were present and pleaded on their loved one's behalf the effort made to revive a patient was greater. Instead of wearing a suit, I suggest that people expecting a heart attack bring their friends and relatives along.

Stefan Timmermans is assistant professor in sociology, Brandeis University, Massachusetts. His research will be presented at the British Sociological Association next week.

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