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Newspapers do not publish articles on such broad topics as the closure of rehabilitation beds and the broader social benefits to be had in ensuring that the older person gets a comprehensive geriatric assessment (CGA) before being transferred to long term care.
The genuine propagandist must be master of the “popular soul”, said Josef Goebbels on the matter of manufacturing social values for the consumption of the masses. The fact that Goebbels and his cronies succeeded so well in inculcating the German people with the idealogy of that time doesn’t say much for the ability of Joe Public to reach a constructive and sensible opinion on his own. Every nation has its Josef Goebbels, be its name Alistair Campbell, Rupert Murdoch, ABC or Fox News. This is not a statement about the political idealogies espoused by those individuals and entities. Whatever their political hue, like Josef Goebbels, they are all masters of propaganda and of the popular soul.
Box 1:
Sir
As a hospital doctor caring for frail and sometimes terminally ill older patients on a daily basis, I am writing to express my concern over the way in which this article was presented. The sensational and accusatory headline does not reflect the balance within the article.
Needless to say, I have every sympathy for any family watching their loved one gradually dying in hospital and I, along with all my colleagues would condemn absolutely, the deliberate starvation or nutritional neglect of an older person who could swallow safely and wished to eat. However, there is much general misinformation around the subject of end of life nutrition and hydration in older inpatients which needs to be corrected. In particular:
a) Many patients with stroke are unable to swallow safely so that eating and drinking would result in distressing choking fits or potentially fatal pneumonia. To allow them to eat and drink normally would be dangerous and totally irresponsible.
b) In such circumstances, drips are there to provide hydration and are not intended to provide sufficient calories. There does come a point, however, when veins are very difficult to find or when patients (such as Mrs Nockels was reported to be) are very swollen and overloaded with fluid, where re-siting drips again and again is positively harmful.
c) Nasogastric feeding tubes can be used to deliver nutrition but they are not without complications such as agitation, distress, infection or trauma. More to the point, repeatedly inserting a tube in a patient who is pulling the tube out or expressly refusing it constitutes assault.
d) Gastrostomy (PEG) tubes can also be used for feeding, but they can only be inserted in patients who are fit enough for the procedure and again may lead to a host of complications. More to the point, there is no clear evidence in either stroke or dementia that their use for feeding improves outcomes.
e) Many older patients towards the end of life or with conditions such as dementia, lose interest in food and fluids and gradual reduction of intake is part of the natural process of decline and death in some individuals. It would be wholly wrong to force food upon them repeatedly.
f) There is no evidence that IV fluids improve comfort or thirst at the end of life, so that emotive language such as "died of thirst" is unhelpful. Most of us would regard the ideal death as either one at home, surrounded by family, or in a hospice - as hospices have pioneered high quality care for the dying. Yet in neither of these settings would the dying person be placed on a drip. So why should a dying patient in hospital necessarily be on intravenous fluids right up to the moment of death?
g) If there is doubt about a patient's mental capacity or prognosis in these circumstances, it is good practice ethically and legally to get a second opinion - as the hospital in this story did. There was clearly a mismatch between the trained professionals' view of Mrs Nockels' outlook or cognitive abilities and the perceptions of the family - who were understandably willing her to get better. Yet you seem uncritically to have accepted the family's version and done little to redress the balance. A frail 91 year old lady with a severe stroke is likely to do very badly and it would be no surprise to the professionals involved that she ran a downhill course.The sensationalist tone of your headline, your failure to reddress the balance in the wake of the coroners' verdict will serve only to misinform and frighten the families of other older patients admitted to hospital.
Yours faithfully
Dr David Oliver
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It goes without saying that “popular soul” has little to do with Madonna or Simon Cowell but we’ll say it anyway. It is that intangible, intractable yet peculiarly malleable entity which, if played well, can either sit around for decades in pubs or in front of the television like so much inanimate jelly, or it can be the powerful, sometimes ferocious force which drives social revolutions.
It is this popular soul and those who understand it, that the BGS finds itself confronting when it decides, in all good faith, to “become more political” in the interests of raising public and policy makers’ awareness of what constitutes good health care for older people.
The BGS understands that in order to influence the policy makers, the popular soul needs to be sufficiently galvanised for the “system” to move the health care of older people up the agenda for resources. While tackling the policy makers through active liaison with the Department of Health, the Healthcare Commission and other relevant bodies the BGS also needs the public to understand the importance of such abstract concepts as CGA, and chronic disease management.
But have you seen any articles in the health sections of the “Times”, the “Daily Mail” or any of the media on such weighty concepts as CGA, or even on the issue of continuing bed closures?. I’m sure you haven’t. It’s not for lack of writing them. They simply don’t get printed - because the “Times”, the “Daily Mail” etc. have an intimate grasp of popular soul in a way that the BGS has in concept only..
David Oliver has been particularly active in doing battle with the media and has learned the hard way that society’s opinion makers want to “get down and dirty”. Don’t give us the bigger picture, they say, give us the small, dirty, sensational stories which illustrate the bigger picture. Of course, the professional geriatrician cannot do that.
But all is not lost, because individuals continue to chip away at the misconceptions which the younger, non-frail Joe Public has about his elders and, to their credit, some of the media allow these gems of enlightenment to appear on their pages. It is these quiet warriors that this article wishes to acknowledge.
Doctors ‘left elderly stroke victim to starve to death’
“She pleaded to be fed, inquest is told. Drip was turned off for four days” - the headline in The Times in January, and a beautiful example of “getting down and dirty” to illustrate a bigger picture of professional incompetence and callow neglect. The fact that the story was a distortion of the facts, and that the doctors in question were completely exonerated (a fact reported some days later, but in small print only,) was beside the point. But one geriatrician stepped up and took issue (box 1).
Doctors in NHS biased against over 65’s
- the uncompromising headline in The Telegraph of 14 February. Again, it took a letter from one individual to try to redress the imbalance (box 2).
Box 2:
Sir,
It is a pity that your Medical Editor has seen fit to produce a lead article which implies that age discrimination is rampant within the medical profession. The British Geriatrics Society represents some 2,400 geriatricians, many of whom work within the NHS and I can state without doubt that I have never worked with a more caring, professional group of doctors in my career. BGS members strive daily to provide their patients with the best possible outcomes.
The report published in Quality and Safety in Health Care represents a tiny sample of patients presenting one condition (cardiac disease) and indeed states that “…a more substantial body of precise
evidence is needed to verify this (the findings) and to document the processes involved.”
For the Daily Telegraph to take this research and imply that all doctors are practicing age discrimination is journalism that is unworthy of your paper. Geriatricians will continue to provide the frail older person, who usually presents with multiple conditions both physical and mental, with a service that is the envy of the world, and that in the face of rapidly disappearing rehabilitation and community facilities which makes their job all the harder.
Yours faithfully
Alex Mair
Chief Executive
British Geriatrics Society |
Let older folk in care die
- a headline commented on in the March 2006 issue of this newsletter, in response to a paper written by a number of geriatricians, calling for resuscitation policies in care homes to be reviewed in light of the largely unpleasant after effects for many survivors of these resuscitation attempts.
Dr Harwood (who happened to be one of the authors of the maligned paper) had an eloquent defence published (box 3).
Dear Sir
I am a Geriatrician and I fight ageism every working day. I firmly believe in modern, effective, medical care for all ages.
What is involved here is not denying care. It is not letting people die. Or euthanasia. It is not about denying appropriate preventative, therapeutic or palliative medical or nursing care. Or about denying information, respect, dignity or choice. It is about what you do when someone’s heart has stopped.
If you have just had a heart attack (blocked artery damaging the heart muscle), which is when your heart is most likely to stop, then you have a reasonable chance of being revived by electric shock treatment to the heart, especially if you are in a bed on a coronary care unit. At any age. No question.
If you are a resident in a care home, you are there because of multiple medical problems and disabilities. Attempts to restart a stopped heart do not work. This is not discrimination but simply a recognition of what works and what does not.
Yours sincerely
R Harwood |
Do not face quietly, the withering storm
to misquote Dylan Thomas. Individual letters to the guardians of the popular soul may strike one as being reactive and ineffectual, but coming from a group of people, bound by their professional principles to observe confidentiality and measured judgement in all things, who labour away in a medical specialty largely dismissed by both the mainstream and sensationalists as lacking appeal or glamour, these individuals (and we are sure that there are others whose letters we have failed to see) are the real public relations face of geriatric medicine (and the BGS).
Dave Beaumont
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