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| Email your comments 1. How to prevent inappropriate admissions to hospital 2. Addenbrookes exercise video publicised in the March issue 3. End of Life Care Report (March 2009) How to prevent inappropriate admissions to hospital A patient can only be deemed to be an inappropriate admission after admission to hospital. A patient at home or in the Health Centre may appear to be most appropriate for admission but it is only after admission that they can become inappropriate. To avoid such inappropriate admissions, General Practitioners should be persuaded to stop sending patients for admission to hospital and Receiving Doctors should be trained in how to refuse any who are referred, tactfully. This will save the Country even more money than encouraging assisted suicide and we may never see a credit crunch ever again. Dr C Cohen Reference: Addenbrookes exercise video publicised in the March issue What a fantastic idea – all we need to do at our Trust now, is persuade Patientline to replace the bedside televisions on our elderly medicine wards (removed as not making enough money!!) Bridget Leach End of Life Care Report (March 2009) I was alarmed to read the following statement in the précis of the NAO End of Life Care report. ‘The report suggests also, that DNR orders are not being communicated to all the multiple agencies involved in care, leading to inappropriate hospital admissions.” The purpose of a DNR order is simply to indicate either that a clinician believes that cardiopulmonary resuscitation would not restart the heart or breathing and therefore should not be undertaken when the heart or breathing stop, or that the patient has decided, with or without detailed consultation with the clinician, that they would not wish the procedure to be undertaken when their heart or breathing do stop. It applies to that decision, and that decision alone. In my current hospital practice I sense increasing unease amongst many colleagues that a DNR order is taken as shorthand for “do nothing except keep the patient comfortable” - doing nothing often meaning not even assessing to see what may have gone wrong, when something suddenly does go wrong. As such, an increasing number of patients are left as “for resuscitation” to ensure they still have the chance of active management when the Hospital At Night team is suddenly called. I have little doubt - and the NAO statement would seem to support the view - that the presence of a DNR form in a patient’s house will often be interpreted - by those called to make rapid judgements about what is best - in much the same way. “Not for resuscitation” quickly becomes “not for hospitalisation”. Perhaps the article simplified what the report said? And that review of the individual patient, their problems, the potential treatments, and the detail of any anticipatory care plan that exists, followed by a discussion with the patient to see if they have changed their mind about previously expressed “preferences”, might better inform whether or not hospital admission would be appropriate? In fact not, the report itself says exactly the same. There is a very fine line to tread between minimising the inappropriate admission of clearly terminal care home residents to acute hospitals for a final 24 hours of life before death – a desirable aim to my mind - and creating an obstacle to access to acute care for older people or those with chronic disease. A single form, designed to cover a single decision, cannot substitute for individual patient assessment. But it may well do so – people like shorthand. Andrew Elder Thanks for your letter. In short, I couldn't agree more. As Rowan Harwood wrote in the Daily Mail after sensationalist reporting stirred up on the back of the BMJ article by Conroy et al 2007, "DNAR is not about denying older people treatment. It’s about what happens when your heart stops." When asked to make these decisions in my own practice, I am keen to emphasise for certain individuals that DNAR does not debar a patient from all manner of other interventions e.g. for sepsis, shock, dehydration, syncope, hypoglycaemia, arrhythmia etc. - and that’s for patients on hospital wards. If they are in long-term care or in their own homes, it would be a big mistake to assume that DNAR equates to "dont call the GP" or "don't convey to hospital". Of course, older people deserve access to high quality end of life care and should not be subjected to burdensome or futile treatments or treatments which they have explicitly refused as part of care planning. But if we want palliative care or we want to proscribe certain interventions, then we should be explicit about this and not use DNAR as a catch-all term. It is a shame that many journalists and members of the public already conflate "DNAR" with "do not attempt treatment of any kind - the patient is too old to bother with" and we need to combat this misconception. In the BMJ 1 May 2009, Daniel Sokol wrote a piece about the use of AND ("allow natural death") as an alternative to "DNAR" but to my mind that is more fraught and open to misinterpretation as it is not sufficiently specific. I mean, technically, I could get pneumonia or maybe swine flu tomorrow and it would be the "natural" course of the illness for me to remain untreated. I think when we write DNAR or make any other advance decisions we need to be very specific about what level we want to treat the person to. David A question of gender The BGS newsletter of March 2009 devoted 9 pages to a debate on the state and future of academic geriatric medicine. The 8 contributing authors shared more than knowledge and achievement – they were all men. In fact, the only allusion to women at all was a discussion of the inconvenience caused by the “reproductive track record” of registrars in the north of England (1). Zoe Wyrko, SpR Geriatric Medicine, Heart of England NHS Foundation Trust; Chair BGS Trainees Committee. Emma Vardy, Walport Clinical Lecturer in Elderly Medicine, Manchester Claire Steves, Wellcome Fellow in Geriatric Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London References Editor’s reply: We have had one female president (indeed, only one female candidate for the presidency), and no female candidate standing for the Secretary’s posts has ever lost out to a male candidate, so I don’t believe anybody can insinuate that the BGS has a “jobs for boys” mentality. It is a fact that when advertising posts on BGS committees, it is mostly men who put themselves forward. There is no bar on female doctors volunteering for various committee or external roles within the BGS, nor submitting articles to the newsletter. If you would like to write a piece on females in academic geriatrics and problems they might face we would be delighted to publish it. BGS Newsletter, March 2009 |